Health Assessment Paper Essay Example

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