Health Assessment Paper

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Health Assessment Paper
I.) IDENTIFICATION DATA
a.) Gender- Female
b.) Birth Date- June 4, 1980
c.) Birthplace- Denham Springs, Louisiana
d.) Education- Diploma from Bob Jones High school/Currently enrolled at UAH e.) Marital Status-.married
f.) Religion- no religious preference
g.) Cultural Background (Race/National Origin)- Caucasian h.) Occupation- unemployed
i.) Insurance Coverage- United Healthcare
II.) SOURCE
a.) pt/Erin Howard, source is reliable
III.) REASONS FOR SEEKING HEALTH CARE
a.) Pt states, “I am here today because of shortness of breath, coughing, and chest tightness.” IV.) HISTORY OF PRESENT ILLNESS
a.) Pt complains of tightness in the chest, followed immediately by coughing, and shortness of breath after working in the garden. Symptoms were first noticed today and worsen when exposed to pollen and cat dander. Alleviation of symptoms occurs immediately with the use of a bronchodilator and oxygen therapy. Pt complains that these symptoms greatly affect daily activities. V.) PAST HEALTH HISTORY

a.) Chronic Illnesses- Pt denies past history of diabetes, hypertension, heart disease, HIV infections, Aids, Sickle-Cell Anemia, cancer, depression, hepatitis, bronchitis, emphysema, and seizure disorders. Pt confirms previous medical diagnosis of asthma at age 10.. b.) Accidents- Pt denies any auto accidents, bone fractures, penetrating wounds, minor or major head injuries, and moderate or severe burns. c.) Hospitalizations- Pt confirms one hospitalization at Crestwood Hospital for the birth of her daughter performed by Doctor Krishna Kakani on June 2, 2004. Hospital stay lasted 48 hours. d.) Surgeries- Pt denies any past surgeries.

e.) Immunizations- Pt confirms immunizations during childhood for measles-mumps-rubella, diphtheria-pertussis-tetanus, and varicella. The sequence hepatitis B immunizations were obtained during the second half of 2011. Last tuberculosis skin test was received on March 27, 2012. f.) Childhood Illnesses- Pt denies ever having the measles, mumps, rubella, pertussis, polio, strep throat, rheumatic fever, scarlet fever, and poliomyelitis. Pt confirms one chicken pox infection at age 5. g.) Allergies/Reactions- Pt denies allergies to medication, food, fabrics, dyes, and insects. Pt confirms allergies to cat/dog dander and pollen with symptoms of watery eyes, shortness of breath, and coughing. h.) Current medications- Pt confirms use of symbicort inhaler as needed on a daily basis to treat asthma symptoms, and she is taking 1 tri-sprintec pill once a day as a method for birth control. i.) Recent Travel (out of state or country)- Pt denies any recent travel out of state or country. j.) Military Service- Pt denies any past or present military service. k.) Obstetric History- Grav-1, Term-1, Preterm-0, Ab-0, Living-1. Pregnancy spanned 40 weeks, labor lasted for 12 hours, female child, 7lbs. 13 oz., and a score of 10 on the Apgar scale. VI.) PERSONAL HABITS

a.)Tobacco- smokes 5-10 cigarettes a day times 7 years
b.)Alcohol- drinks (4) 12 oz glasses of wine on weekends times 4 years c.)Coffee, tea or other caffeinated beverages- pt denies consumption of any coffee, tea, or caffeinated beverages d.)Soft drinks- pt denies any consumption of soft drinks

e.)Recreational Drugs- pt denies the use of any recreational drugs (cocaine, marijuana, methamphetamine, heroin, psychedelic mushrooms, opium, LSD, barbiturates, or ecstacy) f.)Guns in house- no guns owned by pt

VII.) NUTRITION
a.) Dietary Patterns- pt consumes 2-3 (5oz) servings of red meat per week, 2 (3oz) servings per day of vegetables (broccoli, celery, corn, green beans, lettuce, and onions), and 1-2 (3oz) servings per day of fruits (bananas, apples, pears, pineapple, and strawberries) b.) 24 Hour Recall- 100 mL of milk, 1600 mL of water, 480 mL of propel,240 mL of cereal, 120 mL salad, 10 mL of shredded cheddar...
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