Health History

Demographic Information

V. M. is a 72-year old white female who was born in Southern Missouri. She appears younger than the stated age and speaks with a French accent. She is a high school graduate and she is presently from any restraint work. She is married and with three children, a son and two daughters. The daughters are married while the son lives in North Carolina but occasionally pays her a visit Her husband passed away three years ago and she currently lives in a one-bed room apartment on first floor with a house girl  to aid  her in the house keeping chores.. She drives her own car and seeks health care in a community hospital that is 6 miles away from her home. The client does so for routine check-up.

Chief Complaint

The client has experienced “severe and unprecedented” headaches in the forehead accompanied by nosebleeds for the last 3 days, a situation that has led her to seek medical attention. The condition, she says, is aggravated by her early rising and forward leanings while doing household chores. M.V. adds that the headache is relieved when she rests on her back or washes her head in cold water.

Past Medical History

The client understands that she has adult on-set diabetes mellitus [type 2], which she controls with an 1800-caloric diet and moderate diet. She also has mild rheumatoid arthritic pains in right hip and finger joints during early mornings but she relieves them by exercising, ASA and warm baths (Jarvis, 2011).

The client underwent an appendectomy at the age of 18. She also had a cholecystectomy sixteen years ago due to gas pains she experienced after she ate fatty foods. At the age of 2O, V.M. recalls having a left arm fracture of which she was treated in a local hospital in her neighborhood but she says she liked the services. She had a pap smear two years ago and recalls that it turned out to be negative. She admits she has had no pregnancy complications or at childbirth. She also adds that she has never taken any birth control pills. The client wears glasses, which she cannot remember when they were prescribed since she grew up wearing them. She, however, remembers changing them from bifocal to trifocal a few years ago. She wears dentures and had the last dental check two months ago.

Family Medical History

The client’s family died through an accident when she was fifteen and was raised by her grand parents who passed away due to old age before she got married. Her husband succumbed to lung cancer at 70 after years of heavy smoking and drinking. The patient says she is not aware if there is any one in her line age who has or had a chronic or terminal illness. Her three children are all physically fit except for the usual colds that last for a day or two and which she says are normal to every one.

Family and Social Relations

The patient has been married for the last 50 years. Despite her husband a heavy drinker, she says that their marriage had being a happy one. She particularly reminisces her hey days when he used to take her out for dinner and cocktail parties. Her relationship with the children is cordial, she says, as they occasionally pay her a visit and her too. The family holds a get-together party every end of year where she even invites friends and neighbors. She adds that she is keen on her birthdays that bring her old friends and workmates at her place. The client says that her neighbors in the apartment that she lives know her as a jovial woman. She also describes herself as a normal, “talkative” and normal person who likes being around people. She admits she has a weakness of worrying over small things and easy irritation a condition she cannot trace its onset.

The patient has a routine fitness plan, which she follows to the latter. She wakes up at 6 in the morning after which she takes her breakfast and does housekeeping chores assisted by her house girl. In the early afternoon, she to the community center to visit friends and take lunch. At around, she goes home and walks for about four blocks with a colleague. She denies feeling fatigued or having palpitations. She also confirms that she does not experience any chest pains, wheezing, cramps, claudication or joint pains. After the walk, the patient goes back home to continue with her crafts. In the evenings, she attends church related activities. She goes to sleep at 10 pm and denies taking any sleep pills.

The patient says she is on a “no concentrated sweet” diet as follows: she takes breakfast of whole-wheat toast, a boiled egg, mango juice and decaffeinated coffee at 7 in the morning. She takes lunch at noon, which primarily consists of fish, salads and milk. She takes a light supper at 6 pm. Her dinner typically consists of a small-serving broiled meat, green vegetables, a piece of fruit and a glass of milk. She tries her best not to snack but opts for a fruit if the urge is too much. The patient takes two 8-oz glasses of water daily. Though she wears dentures, the patient holds that she has no problem with proper fit, eating, chewing, swallowing sore throat tongue or colds except when she eats strawberries (Weber, 2009). She voices no dislikes or food intolerance. The patient showers and washes her hair daily.

Subjective Review of Systems (Jarvis, 2011).

General Survey

The Patient is aged 72 and she is a Caucasian retiree. She looks a bit strained and in pain which approximates to be of a magnitude of 6 in 0-10 where 0 represents ‘no pain whatsoever’ and 10 stands for ‘deep pain and discomfort’ .

HEENT Assessment: The patient wears glasses since her childhood. Her nose is centrally aligned with its membrane being intact and moist. L naris stenos are noted whereas R naris is completely patent. She denies having any L naris dysnea. The patient reports having no problems in breathing or swallowing. Her dentures are intact and she admits that they do not trouble her while chewing.
Respiratory system Assessment: The patient denies having any feelings of fatigue or pain when breathing. She admits that she occasionally has a cough that persists for a day or two but is usually a productive one.

Cardiovascular Assessment: The client says she has never had any heart related complications nor any of her family members.

Musculoskeletal Assessment: The patient admits having back pains when she carries heavy loads. This she suspects is due to carrying large trays in most of her long career as a waiter and cook.

Neurologic Assessment: The client admits that she some times has a weak memory of retaining finer details. She also admits that she is a joker and thus she adopts a light touch on issues.

Genitourinary Assessment: The client denies having any pains while relieving herself or in coital activities.

Objective Review of Systems

HEENT: The Patient shows no contusions, lacerations or bruises in her scalp. Her hair is grayish brown in color, receding, oily, and well kempt with mild dandruff. Her head is micro cephalic with symmetrical ears. Her eyebrows are bushy, and she has bilateral sparse upper and lower eyelashes. Her eye color is brown. Her lips are chapped, a moist oral mucous membrane with no wounds or lesions noted. The tongue is pink with a midline uvula. Her trachea is midline and has no signs of JVD or masses palpated (Jarvis, 2011). Her hearing is intact. She is shortsighted and wears glasses.

Respiratory: All the heart sounds of the patient are ausculated and no abnormities noted. Her pulse rates palpated 2+ and the capillaries refilled after 2 seconds. She had no signs of edema. The patient’s respirations were unlabored and had occurred at the rate of 20/minute.

Musculoskeletal: The patient has a slightly stooped posture with mild kyphosis. Her paravertebrals equal in size and strength. A rheumatic nodule is noted n the dorsal surface of her left hand. She also has a small callus on her left heel. Her muscles are moderately firm bilaterally.

Neurologic: The client has a pleasant demeanor and shows no signs of mental retardation. Her speech is non-delayed and exhibits the appropriate behavior. Her short-term memory is not bad but her long-term memory is a bit weak. Her reflexes are impaired due to neuromuscular dysfunction. She is responsive to touch or prick.

Abdomen: The patient has a mildly protuberant abdomen that is non-distended and symmetric. There are no apparent masses or abnormal lesions. Her bladder is non-distended too and has an inverted navel. Her bowels sound hypo- active.

Genitourinary: There is no bulging or masses in inguinal areas. She has a 1 cm nodule palpitated in her right groin. Her labia are pink with decreased elasticity. There is no bulging of vaginal wall or any purulent, foul smell discharged. Her rectal mucosa bulges with strain.

Nursing Diagnosis Plan (Weber, 2009)

Health promotion diagnosis: The patient shows readiness to enhance her nutrition. This is exemplified by the way she strictly follows her diet regime.

Risk Diagnosis: The patient is at risk of being stressed and has not recovered from the shock of the death of her husband. She feels insecure and that is why she spends most of her time with friends. If she fails to do so, the headache resurfaces.

Summary

The client’s health is not critical and can benefit from increased rests and post-traumatic coiunselling. This will make her come in to terms with the loss of her husband. Increasing the circle of her friends and avoiding boring routinely walks and instead replacing it with outings can be very helpful.