Comprehensive Health History

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Comprehensive Health History-Essay sample

Patient Initials: N.D. Gender: Female Ethnic Origin: Indian Marital Status: Married Occupation: Homemaker Residence: Minnesota Reason for Visit: Throwing up frequently, progressive weight loss, exhaustion, and irritability.(Comprehensive Health History-Essay sample)

Source of Data: N.D. is the primary source of data. She is mentally stable and a consenting adult to provide reliable data.

CC: ” I frequently throw up, my weight is progressively dropping, and lately, I’ve been feeling quite exhausted. I get upset easily and have no control over my emotions.”

HPI: The patient, an Indian woman of 25 years old, arrived at the clinic complaining of exhaustion, frequent vomiting, and increasing weight loss. The patient claimed that lately, she has been irritable and difficult to relate to. She does not feel well and has lost interest in the majority of the activities she was doing. Because she gets tired easily, the patient does not exercise as frequently as she did in the past. She has been largely inactive during the previous month. Her mood and weariness are impacting her functioning. She noted that she was no longer as adept or swiftly performing household duties and daily activities. She said she started a weight loss program a year ago to prepare for her wedding, restricting her diet and starting long-term exercise. She acknowledges that she feels more attractive now that she’s lost weight thanks to the program. Even after reaching her goal weight, she maintained the same program. (Comprehensive Health History-Essay sample)

Allergies: The patient is allergic to animal fur and grass pollen.

Current Medications:

• Xanax for her anxiety.
• The patient reports using Bupropion-naltrexone to help her with weight loss.
• The patient denies using any herbal remedies.(Comprehensive Health History-Essay sample)

Past Medical History:

General Health Status: Patient says she has been healthy most of her life, with only some childhood illnesses like measles and chickenpox and occasional colds and stomach issues.

Childhood illnesses: The patient reports developing measles and chicken pox when she was young but was immunized for the same.

Major Medical/Chronic Illness: Patient denies any major medical history

Accidents/Injuries: Patient denies accidents or injuries

Surgery: Patient denies any surgical procedure.(Comprehensive Health History-Essay sample)

Obstetrical/Sexual history: Sexually active. She is not under birth control. The patient reports irregular menses since a year ago and amenorrhea for the last two months.

Past Psychiatric History:

• Hospitalization: Denied previous hospitalization
• Medication trials: No previous medical trails(Comprehensive Health History-Essay sample)
• Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnosis

Immunization:

• MMRV for measles as a child
• Varivax for chicken pox as a child
• Flu vaccine 9/10/2022
• Covid-19 vaccine 4/1/2023

Examination/Screening Test:

• Pap Smear test in 2019, negative
• Dental examination in 2020 showed a cavity on the lower right molar
• Covid-19 test 15/8/2021, negative

Family History: The patient denies any significant medical history in the family. Mother is 52, alive and well. Father is 55, alive but suffered a bone fracture on the right leg but is mobile. Brother is 23 years, alive and well. Sister is 19 years, alive, and well. The patient does not know the grandmother and grandfather’s health history. Grandmother died at 72, and grandfather died at 70.(Comprehensive Health History-Essay sample)

Personal/ Social History: N.D. moved from India to America with her parents when she was 10. She is now 25 years and married. She has lived with her husband in Minnesota since their wedding six months ago.

Education and Occupation History: N.D. is educated to college level and works as a homemaker.

Functional Status: The patient reports the ability to perform activities of daily living but states getting tied easily and decreased efficiency and effectiveness in completing house chores. The patient denies a history of abuse within the family.(Comprehensive Health History-Essay sample)

Nutrition History: The patient reports dieting to have a lean body in preparation for her wedding. The patient states she reached the ideal weight but continued with the same program after the wedding. Her diet is highly restrictive, taking small meals twice a day. The diet primarily includes minimal carbohydrates and proteins and a lot of leafy vegetables and fruits.

Health Regimen: The patient reports exercising daily, sleeping adequately, and developing an effective work-life balance. However, she has struggled to exercise because she easily fatigues.(Comprehensive Health History-Essay sample)

Habits: The patient reports taking a lot of caffeine and three cups of sugarless coffee every day. She denies any history of alcohol or substance abuse.

Safety Practices: Patient reports using seatbelts when driving, helmets when riding a bicycle, and applying sunscreen when outside.

Support System: Patients family is the primary support system. She prefers talking to her mother when stressed and her father when she has an emergency. Her husband is mostly at work.

Source of Health Care: The patient reports health issues to the family doctor. She received an assessment one week ago before being referred to this visit.(Comprehensive Health History-Essay sample)

Cultural Assessment: The patient and the family still observe their Indian culture. The patient and family celebrate every Indian holiday.

Spiritual Assessment: The patient practices Bhakti yoga.

Legal History: The patient denied any legal history.            

ROS:  

General: Reports gradual weight loss, fever, weakness, and fatigue.

HEENT: Eyes: Patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.(Comprehensive Health History-Essay sample)

Skin: No rash or itching.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Gastrointestinal: The patient reports eating restriction, nausea, vomiting, and diarrhea. No abdominal pain or blood. The patient reports reduced appetite and constipation.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, and odd color.

Neurological: The patient reports frequent headaches and denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports concentration and attention problems.(Comprehensive Health History-Essay sample)

Musculoskeletal: The patient reports muscle pain and weakness, and back pain. Denies muscle or joint stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.(Comprehensive Health History-Essay sample)

Endocrinologic: Denies sweating. No reports of cold or heat intolerance. No polyuria or polydipsia.

General Survey:

The patient seems her age, although she appears lean, malnourished, and dehydrated, with the BMI indicating she is underweight. The patient converses appropriately and regularly with the interviewer but appeared irritated with some questions. The patient has impaired concentration but managed to answer questions appropriately after asking to be pardoned. She expressed a low mood, persistent probing, decreased attention and concentration, apathy, and easy fatigability. The patient appeared bleak and expressed pessimistic ideas about her life, marriage, and future, fearing her husband would leave her. She reports suicidal ideation but negative active plans. She denies homicidal ideation.(Comprehensive Health History-Essay sample)

Vital Signs: Unstable

Temp: 98.8F

B.P.: 100/55

P: 60

R.R.: 15

O2: Room air

Pain: 4/10

Ht: 5’5 feet

Wt: 95 lbs

BMI: 15.8

BMI Range: Underweight

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.

Cardiovascular: The patient’s heartbeat and rhythm are slow. The patient’s heart rate is slow, and capillaries refill in more than two seconds. The patient shows signs of hypotension.

Musculoskeletal: Normal range of motion. Low muscle mass for age. No signs of swelling or joint deformities. The patient indicates muscle wasting. Muscle and back pain is rated 4/10 on the pain scale.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear. The patient has frequent headaches. The patient shows signs of mineral and vitamin deficiencies.

Psychiatric: The patient has a depressed mood, irritability, insomnia, and impaired concentration.

Neuropsychological testing: Social-emotional functioning is impaired.

Behavior/motor activity: Patient behavior was appropriate and constant throughout the assessment

Summary:

Strengths:

1. Regular exercise: research shows regular exercise is a health promotion approach, helping maintain fitness and a healthy weight and reduce the risks of illnesses like osteoporosis, obesity, diabetes, and hypertension (Padavinangadi et al., 2019).
2. No alcohol or substance use: uncontrolled alcohol and substance use are associated with significant health issues, including throat, lung, skin, and stomach cancers and addiction.
3. Regular meditation and Yoga: Meditation and yoga are linked to positive behavior and promote mental health (Sunita et al., 2022).

Risks to Health

1. Diet restrictions: under-dieting is associated with nutrition deficiencies linked to multiple health complications, including unstable mental health and emotional regulation due to impaired mood (Guerdjikova, 2021).
2. Overtraining: patient reports exercising for extended periods. Overtraining is associated with eating disorders like anorexia athletica (Dittmer et al., 2018).
3. Pessimism: The patient reports increased pessimism linked to mental health problems like increased anxiety, stress, and depression (Zou et al., 2022).

Plan to Address Diet Restrictions

The patient’s health problems emerged due to diet restrictions, exposing the body to nutrient deficiencies.

1. Behavioral changes: The patient requires behavioral adjustment to encourage healthy eating. Cognitive behavioral therapy will help address behavioral changes to control eating and body perception (David et al., 2018). Self-control is required for successful behavioral changes, making CBT a fundamental intervention and teaching instrument.
2. Meal plans: The patient needs to adopt meal plans to ensure a sufficient supply of nutrients and a weight increase to a healthy range (Padavinangadi et al., 2019). Meal plans are critical to addressing eating disorders; the patient will work with a dietician to prepare them.
3. Exercise plan: Meal plans have to align to exercise plans. Meals and exercising are important to gaining weight as they are to losing. Therefore, adjusting the exercises, including frequency and type of exercise, per the meal plan is integral to getting positive outcomes (Padavinangadi et al., 2019). The patient should shift to more weight lifting exercises 3-4 days a week while maintaining a high carbohydrate and protein diet to gain weight.(Comprehensive Health History-Essay sample)

Reflection

The primary challenge in the teaching plan was that the patient did not realize the severity of her situation or the risk associated with nutritional restriction. The patient also exhibited increased anxiety, irritability, and impaired concentration, limiting cooperation. The patient had little knowledge about the link between eating disorders and mental health, which made her weigh down the impact of her eating pattern on her mood and emotional instability. The husband was less involved in the process because of his busy schedule. In another encounter, I would appreciate the presence of the husband, who currently resides with the patient and better understands or perceives the patient’s lifestyle changes. The successful completion of the teaching required commitment from the patient and a reliable support system because the risk of relapse is high. The patient’s mother and father were great facilitators of the teaching process, acting as the support system.  (Comprehensive Health History-Essay sample)

References

David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Frontiers in psychiatry, 9, 4. https://doi.org/10.3389/fpsyt.2018.00004

Dittmer, N., Jacobi, C., & Voderholzer, U. (2018). Compulsive exercise in eating disorders: proposal for a definition and a clinical assessment. Journal of eating disorders, 6, 42. https://doi.org/10.1186/s40337-018-0219-x

Guerdjikova, A. (2021, February 8). Dangers of dieting: Why dieting can be harmful. Lindner Center of HOPE. https://lindnercenterofhope.org/blog/why-dieting-can-be-harmful/

Padavinangadi, A., Xuan, L. Z., Chandrasekaran, N., Johari, N., Kumar, N., & Jetti, R. (2019). The Impact of Eating and Exercise Frequency on Weight Gain – A Cross-Sectional Study on Medical Undergraduate Students. Journal of Clinical and diagnostic research: JCDR, 11(2), IC01–IC03. https://doi.org/10.7860/JCDR/2019/25346.9458

Sunita, Lata, M., Mondal, H., Kumar, M., Kapoor, R., & Gandhi, A. (2022). Effect of Practicing Meditation, Pranayama, and Yoga on the Mental Health of Female Undergraduate Medical Students: An Interventional Study. Cureus, 14(9), e28915. https://doi.org/10.7759/cureus.28915

Zou, R., Hong, X., Wei, G., Xu, X., & Yuan, J. (2022). Differential Effects of Optimism and Pessimism on Adolescents’ Subjective Well-Being: Mediating Roles of Reappraisal and Acceptance. International journal of environmental research and public health, 19(12), 7067. https://doi.org/10.3390/ijerph19127067