Health History of The Adult
Shandy Alexander
New York City College of Technology
NUR 3010 Section 8500
February 22, 2012
Professor Okumakpeyi

NEW YORK CITY COLLEGE OF TECHNOLOGY
Department of Nursing
NU 301

HEALTH HISTORY OF THE ADULT

INITIAL INFORMATION

1. Date and Time of History: 02/ 19/2012, at 1:00 p.m.

IDENTIFYING DATA

1. Name: J.S.
2. Address: 146 E 96ST Apt 1R
3. Age: 31 years
4. Date of birth: April 11, 1980
5. Birthplace: Saint Lucia
6. Gender: Female
7. Marital Status: Single
8. Race: Black
9. Ethnic Identity/Culture: African American
10. Religion and Spirituality: Seventh’s Day Adventist
11. Occupation: Teacher
12. Health Insurance: United Health
13. Source of history: Client
14. Source of referral (if appropriate): Nutritionist, Dietitian

RELIABILITY:

CHIEF COMPLAINT (s) (CC): to establish the major specific reason for the individual’s seeking professional health attention: I have knee and back pain and a tingling feeling in my left hand. I haven’t seen my period in a month and a half and I have Type 2 Diabetes.

PRESENT ILLNESS (PI): to obtain all details related to the chief complaint. Type 2 Diabetes
.
1. Onset
a. Date of onset: Back pain started three weeks ago after I nearly fell of the steps of the three train station. Knee pain started 02/18/12 after dancing. The tingling feeling in my hands started June last year.
b. Manner of Onset: The tingling feeling moves from my hand to my shoulders.
c. Precipitating and predisposing factors related to onset (emotional disturbance, physical
Exertion, fatigue, pregnancy, environment, injury, infection, toxins and
Allergens or therapeutic agents): My back pain depends on my sleeping position. Dancing, high heels and walking up the stairs aggravates my knee pain. Cooking and lifting up heavy stuff aggravates the tingling sensation in my left hand.

2. Characteristics
a. Character (quality, quantity, consistency, or other): Back pain is in the lower left region, it is a number 10 on the pain scale. It started three weeks ago, it last until I take pain killers and I feel this pain every morning.
The pain is in my left knee, it is a number 10 on the pain scale, walking up the stairs aggravates my pain, elevating my knee and taking pain killers makes it feel better. My knee swells up when it is painful.
I feel a tingling sensation in my left hands that moves towards my shoulder, it is an unbearable, annoying feeling, physical therapy makes it feel better but cooking and lifting heavy stuff makes it feel worse.
b. Location and radiation (i.e. pain)
c. Intensity or severity
d. Timing (continuous or intermittent,)
3. Course since onset
a. Incidence
(1) Single acute attack
(2) Recurrent acute attacks: My knee and back pain and my tingling sensation come and go.
(3) Daily occurrences
(4) Periodic occurrences
(5) Continuous chronic episodes
b. Progress (better, worse, unchanged): The back pain and knee pain has gotten better because of the pain killer and the tingling sensation has also gotten better because of the physical therapy.
c. Effect of therapy

Past Medical History:

Childhood:
1. Illness
2. Immunizations: MMR, Hepatitis C, flu vaccine in November, 2011
3. Allergies: Dust

Adult:
1. Illness (physical, mental and emotional): Diabetes Type 2
2. Surgical : D& C in 2008
3. Obstetric/gynecologic: I have an irregular menstrual period but when I take my birth control pills, it comes regularly. There was a time where I did not see my period for six months.
2. Substance Use (Alcohol, Smoking, Drug Abuse); No alcohol, smoking or drug abuse
3. Adverse Drug Reactions: no reactions to medications
4. Medications: Name, dose, route, frequency, duration, and reason for administration.
Kombiglyze, 5mg, by mouth, once a day for a month for type 2 Diabetes
Ibuprofen 600 mg, by mouth, whenever I feel pain. I have been taking it for 1 month now for the back pain and two days for the knee pain.
Bayer aspirin 81 mg, by mouth, three times a week to prevent further clot formation. Last year he doctor saw blood clots around my heart.
5. Herbal Supplement/Over the Counter Drugs: No
Past Surgical History
1. Hospitalization: Hospitalized in 1996 for seizure
2. Outpatient Care
3. Transfusions: NO

Family History:
1. Immediate Family: Father (70 years) has diabetes and high blood pressure, mother (60 years) has diabetes, glaucoma, astigmatism, grandmother ( was 93 years, died from stroke) had astigmatism, grandfather (was 77 years, died from prostate cancer) had diabetes
2. Extended Family
3. Genogram

Psychosocial History:
1. Occupational History: Nanny for 4 years, Educational director for7 years at Sparkles, Teacher at Sparkles
2. Education: Bachelor’s in Education, Bachelor’s in Science
3. Financial Background: middle class
4. Roles and Relationships: Sister, good friend
5. Children and ages: No children
6. Sexual History: 2 partners
7. Exercise: twice a week on the exercise ball
8. Pets: no pets
9. Exposures (Asbestos, 9/11): NO

.
REVIEW OF SYSTEMS (ROS): to elicit information concerning any potential health problem.

1. General –
Lately I have been eating a little bit of food but feel hungry very fast. The doctor says that my hunger is because of the Diabetes. I crave a lot of salad. I have lost fifteen pounds. I also have a very low sex drive.
2. Integument –
): My skin feels warm, it is a little bit dry and my hair is healthy and strong; no breakage.
3. Head, Neck & Lymphatic’s –
When my blood sugar is low, I get a slight dizzy spell.
4. Eyes –
I use glasses for astigmatism. I have been using glasses for 2 years now. I use it to read. I my last optic exam was sometime last year, I cannot remember the date.
5. Ears – No discharge except for ear wax and no hearing loss.
6. Nose-
I have sinus and my nose bleeds in the winter when it is too cold.
7. Mouth –
My gums bleed when I brush my teeth. My last dental visit was 6 months ago.
8. Throat – No sore throat, chewing difficulties or hoarseness.
9. Neck – No pain, stiff neck or lumps
10. Chest – No masses, lumps or breast enlargement.
11. Respiratory –
I had a cold 4 days ago. I get shot of breath after running for the train or climbing a lot of steps. I have sinus. My last tuberlin test was in September, it was a negative reaction.
12. Cardiovascular /Peripheral Vascular
I have anemia (Iron deficiency). I went to the doctor on Wednesday (02/15/2012) and it was difficult to get blood from me.
13. Gastrointestinal –
I do not have a good appetite. My diet has changed because of my Type 2 Diabetes. I eat less sugary substances and starchy foods. I felt nauseous after taking my diabetes medication for the first two days but now I do not affect me.
14. Genitourinary –
I go to the bathroom very often because I drink a lot of water and because of my diabetes. I had a urinalysis done on Wednesday (02/15/12).
15. Gynecologic –
I first saw my period when I was 13 years old. My last menstrual period was January 8, 2012. My period is usually irregular but gets regular when I take my birth control pills. I did a pap test 6 months ago and everything was fine.
16. Musculoskeletal- Good range of motion
17. Neurologic- I only had one seizure attack, in 1996. I was in church when it happened.

STAGE OF DEVELOPMENT:
Erickson: Young adult (19-45 years) Intimacy versus Isolation
Intimacy is when a young adult allows close attachment. They feel comfortable around people, they let people in, they trust people with their heart, and they have good social skills and a good social life. Isolation is when a young adult does not form a close, trusting bond with others. They feel that no one cares and they have no one to talk too.

ACTUAL FINDINGS
I am 31 years old. I am happy when my friends are around. I have a good social life. Friendship means a lot to me. I know that I can always call on them or my sister if I need advice. I am single but I remain good friends with both my ex-boyfriends. I believe that god will send me a good husband. I have been praying for that.

DIETARY HISTORY

A nutritional assessment is an essential part of a complete health appraisal. Its purpose is to evaluate the client’s nutritional status – the state of balance between nutrient expenditure and need.

Which is the family usual mealtime? I have breakfast depending on the time I get up. Sometimes on the weekend I do not have breakfast. I like having lunch at 12. I have dinner between 6 and 7:30.
Do family members eat together or at separate times? I usually eat alone because I leave alone but on weekends , I invite my friends over.
Who does the family grocery shopping and meal preparation? I do all my groceries and meal preparation.
How much money is spent to buy goods each week? I spend about $50 per week.
How most food is prepared – baked, broiled, fried, and other? I usually bake and broil my food.
How often does the family or the client eat out? I eat out once a month.
What kind of restaurants do you go to? I go to fancy cuisines and dinners.
What kind of foods do you typically eat at restaurants? I usually order lamb or salmon.
Do you eat breakfast regularly? I do not eat breakfast regularly especially on weekends.
Where do you eat lunch? I eat lunch at home or work.
What are your favorite foods, beverages, and snacks? My favorite beverage is red wine, for food it is green banana and chicken backs, and my favorite snack is kit Kat.
What is the average amount eaten each day? Under 2000 calories
What foods are artificially sweetened? None
What are your snacking habits? My snacking habits depend on my mood. I eat a lot when I am depress or stressed out.
When are sweet foods usually eaten? I eat sweet foods when I have a craving for it.
What are your tooth brushing habits? I brush my teeth twice a day.
What special cultural practices are followed? I cook all the Saint Lucian dishes on Sunday.
What ethnic foods are eaten? I loving eating banana and salt fish, Saint Lucia’s national dish and dumpling in coco tea for breakfast.
What foods and beverages do you dislike? I hate eggs and apple juice.
Do you use bottled water for drinking? Yes
Do you use a microwave for cooking and reheating foods? I use the microwave to reheat foods.
How would you describe your usual appetite (hearty eater, picky eater)? : I am a picker eater.
What are your feeding habits (eats by self, needs assistance, and special devices)? I eat by myself.
Do you take vitamins or other supplements; do they contain iron or fluoride? No
Are there any known or suspected food allergies? No
Are you on a special diet? Low carb diet
Have you lost or gained weight recently? I have lost fifteen pounds in the past three weeks.
Are there any feeding problems (difficulty swallowing); any dental problems or appliances, such as dentures, that affect eating? NO

PROBLEM LIST

1.___________hyperglycemia or hypoglycemia____ (risk for orthostatic hypotension) _____________________________________________________________

2.______neuropathy (tingling sensation in the arms)______________________________________________________________________

3.____Risk for a CVA or MI due to clot formation around the heart and Diabetes.________________________________________________________________________

4.___ ___Risk for deficient fluid volume related to polyuria and dehydration.____________________________________________________________________

5.___Risk for impaired skin integrity

6.______Activity intolerance related to pain.______________________________________________________________________

7.___Sexual dysfunction: decreased libido_________________________________________________________________________

8.___Risk for fatigue due to anemia_____

9.__Risk for diabetic retinopathy ______________________________________________________________

10.________Risk for nephropathy __________________________________________________________________

SUMMARY OF RECOMMENDATIONS

A 31 year old female diagnose with Type 2 Diabetes. She has a family history of this disease. She complains of knee pain and back pain. She has polyuria, polyphagia and polydipsia, symptoms of the disease. She is currently taking Kombiglyze, 5mg by mouth for only a month per doctor’s recommendation. She is also taking Ibuprofen 600mg for knee and back pain and Bayer baby aspirin 81mg to prevent further clot formation. Client states that physical therapy alleviates the tingling sensation in her arm. Client needs to see nutritionist and Dietitian. Client needs teaching about low carb diet and foods high in iron and folic acid for anemia. Client also needs teaching on side effects of medication and complications of Diabetes.

References

Bare, B., Cheever, C., Hinkie, H., & Smeltzer, S. (2008). brunner & suddarth’s textbook of medical-surgical nursing. (11 ed., Vol. 2, pp. 1375-1435). Philadelphia, PA: Lippincott Williams& Wilkins.
Bickley, B., & Szilagyi, S. (2009). Lynn s. bickley bates’ guide to physical examination and history taking. (10 ed., pp. 5-12). Philadelphia, PA: Lippincott Williams& Wilkins.
Franzoi, F. (2007). Psychology: A journey of discovery. (3 ed., p. 118). Cincinnati, Ohio: Atomic Dog Publishing.