Madam L., aged 52, Chinese, female. Born and lives in Singapore. Client is married and lives with with her husband and their 3 children aged 23, 21 and 19. She converses fluently in English, Mandarin, Teochew and Cantonese. Her highest attained educational level is GCE A levels and is currently employed as a Marketing Manager in UOB travel planners.
On the day of examination, her vital signs were:
Pulse: 70 beats per minute
Respiration: 14 breaths per minute
Blood pressure: 119/65mmHg
1. HEALTH PERCEPTION AND MAINTAINENCE
Client’s Health Perception
Client verbalized that she was diagnosed with high cholesterol in 2008 and was recently diagnosed with Diabetes in 2011. She visits a general practitioner every 2 months to review her medications and has blood tests done for her Diabetes and High Cholesterol every 6 months. Client verbalizes that she takes her medications regularly and has a strict “no overeating” diet, but she does occasionally indulge herself with a sweet treat. Client rates present health at 8 on a scale of 1 being worst to 10 being best. She rates her health 5 years ago to be 9, and rates 8 in the next 5 years as well, as she believes that her current exercise routine of swimming twice a week and her diet will help improve her health status in the years to come. She has no current complaints, is feeling well and does not smoke or drink.
Past health status (including Family History)
Client claims that other than her high cholesterol and diabetes, she is relatively healthy and hardly falls sick. Her 3 children are fit with no past medical conditions. She states that her husband also has high cholesterol but is otherwise healthy. Paternal grandfather passed away in 2000 due to congestive heart failure and paternal grandmother passed away in 1990. Maternal grandparents passed away between the ages of 63-81. Client verbalizes uncertainty of the causes of death of her paternal grandmother and maternal grandparents as the deaths happened when she was young and have never actually asked her parents about it. Her father passed away in 2006 from congestive heart failure and her mother is alive and well. Client states that she is the eldest of 4 children in her family. Her siblings do not have any significant medical conditions. (Refer to Appendix 1: Genogram of Madam L.) Immunisation Status
Client claims she does not remember which specific immunisations she has received as a child but has recently gotten her flu vaccination in mid 2011. Current medications
Subcutaneous Insulin 15units every night (Since 2011)
Metformin 500mg 2 tablets every night (Since 2011)
Glucobay 100mg 1 tablet 3 times a day (Since 2011)
Atorvastatin 20mg 1 tablet every night (Since 2008)
Glucosamine sulphate 1 tablet twice a day (Since 2009)
Vitamin E 1 tablet every morning (Since 2009)
Evening primrose oil 1 tablet every morning (Since 2009) Known drug sensitivity and reactions
Client claims she has no known drug allergies.
Have no food allergies.
Client went to junior college and has attained her GCE 'A' levels. She started working in a travel company as an assistant, where she was then promoted to be a Ticketing Manger. She got married at 28 years old and delivered her first child at 29 years old. She left her first job and joined UOB travel. Roles and Relationships
Eldest daughter in her family and is married with 1 daughter and 2 sons. •
Genogram, refer to Appendix 1
Ecomap, refer to Appendix 2
2. NUTRITIONAL AND METABOLIC HEALTH PATTERN
Client claims to have a strict diet and avoids sweet food and drinks because of her diabetes. Eats about 4-5 small meals a day. Claims to have a balanced diet and consumes vitamin supplements daily, as mentioned above. Client consumes wholemeal bread and wholegrain cereal for breakfast, does not like to drink milk...
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