Medical History
Patient C.W is aged 42 years female black American living in Los Angelis. She is a practising nurse. She holds a licence in vocational nurse. She has a one child whom she is caring. The patient states that she was born in Los Angelis, her parents birthplace is Los Angelis. Her highest level of education is diploma in Nursing.
A 42 years old Black American female came into the ER crying, holding on to her stomach with a bowl in her hand which contained some light food particles from her vomit. The patient complained of “severe abdominal pain, cramping, diarrhea, nausea, and vomiting, mainly around the naval and trunk area of my body, occurring 24 hours at midnight between 12:30am and it’s getting worse.” According to the patient, “I was in good health as I was socializing with my son all day. We both ate a little portion of Chipotle before going to bed. Approximately at 12:30am, I started feeling some light dull pain around the trunk of my body, then visited the restroom six times before daybreak.” According to patient, “The pain radiated towards my belly button and other parts of my stomach. The abdominal pain got worse suddenly. Patient stated” I took Tylenol 650mg oral, and I vomited it out, and the patient stated that her symptoms are triggered by eating, drinking. The symptoms as described by patient is “unable to sleep, severe weakness, can’t sleep, drink, or eat due to the pain. Patient denied fever.”
Patient C.W has a history of gall bladder in 1999 operation and Caesarian assistance 33 years ago. The patient suggests that during the period of C-Section management she didn’t receive any associative complications such as infections, blood loss, bowel problems organ injury or blood clots, (Cunningham et al., 2010). During the childhood ages, C.W was diagnosed with chicken pox, which she states was managed successfully. The patient states that she has never had any injury as a result of an accident. C.W has only undergone operation in medical condition stated above; gall bladder and C- section, (Cunningharm et al., 2010). Her obstetric history condition as stated by her shows that she has 2 gravida children. Further she has had no preterm birth and she underwent full term birth. She currently lives with her one child.
She normally attends immunization engagement as stated by her records of immunization indicates that she took DTaP Date 06/25/2014 Pneumonia on date, Influenza on date 10/12/17, Hepatitis Type B on date e2/2/18, MMR on date 1/5/04, Rotavirus on date 04/6/17, Hib on date 12/17/17, Varicella Date 1/5/04, IPV Date_2/2/18 and TB on date 12/8/17
Immunizations
The patient is undergoing medication which includes Clarithin, Apro and Ferrous sulfate. The patients state that she is allergic to pollen and dust. The intake f Claritin, acts as an anti histamine which acts by reducing the effects of the chemical histamine found in the body which is linked to sneezing and running nose and watery mucous. Also the Ferrous sulfate medication is meant for boost in red blood cell count in the body. Her diagnostic lab tests shows that her CXR, Ekg among others are normal, Jarvis, 2016.
Patient C.W has an history of chronic sinuses which has been itchy since six years ago. She was referred to a social worker and was placed on Claritin drugs and atropine to manage the allergies. The patient denies having cervical cancer, heart disease and hypertension. She denies of any history of smoking nor usage of alcohol. Further despite taking allergy treatment the patient denies allergy on latex allergies or any form of food allergies.
The patient claims to have no history of any illness over the past years . She has been having good weight status and good living practices over the past 13 years since her operation from gall bladder. Patient has denied having any signs and symptoms of fever, fatigued or any weight loss.
The patient body denies having any bruise or any harm on her body. Her body is intact and from the observation, there are no signs of hair loss. She also denies any tattoos. From observation she has brittle nails in good shape.
Head
C.W denies having any signs of headache or migraine health. Health promotion lan is to encourage the patient to avoid exposures which precipitate headache
Neck
The patient denies any form of neck swellings of lesions, or any form of thyroid goiter symptoms. Health promotion plan is to encourage the patient on good sitting and sleeping postures and to ensure proper hair or seat arrangement.
Ears
The patient denies any form of ear infection which can include bloody discharge, infection or excessive hair. Health promotion is to encourage her to keep healthy practices such as avoiding loud music and limiting use of ear phones as they harm the ear drum.
Eyes
The patient denies any form of swelling and redness, cataracts and glaucoma. She states she has no signs of blurred vision, decrease in visual aspects and bloody eyes. Health promotion plan is to ensure that she always go for eyes health check in the eye clinic.
Medication
C.W denies any signs of fever and unexplained colds, obstructions, fever, allergies and changes in the olfactory. Thus the aim of health promotion is to educate the patient of hygiene and cleanliness of Ear Nose and throat. Further the patient denies or pharynx, however plan is to educate the patient to offer on oral hygiene and visitation to the dentists, (Jarvis, 2016).
Patient C.W denies any changes on her health with regard to respiratory and cardiovascular health. She denies having any signs of bronchitis, asthma or tuberculosis, sleep disorder pollution exposure of cough. Plan for health promotion is to educate her to avoid exposure to harmful environmental substances which can affect her respiratory health. Further the patient denies having any signs and symptoms of chest pain, congestive heart failure, stenosis or any heart related pain. However moving forward is to encourage her to always visit health care facility for screening and tests .
C.W denies having any signs of thrombo phlebitis and swelling of the lower extremities. She says she has no heard any signs of swelling, numbness or ulcers., she also denies any signs of breasts cancer or any suspicious discharge or rash on her breast. She asserts that she usually performs self tests breast exam. Health promotion goal is to encourage to undergoes breast screening and maintaining good practices for the management of peripheral vascular disease such as avoiding standing for long and crossing of legs while sitting.
C.W denies having any history of gastrointestinal and genitourinary symptoms. She claims that she has had no urinary tract infections such as hematoruria, dysuria, cloudy urine or other forms of kidney infections. Health promotion plan is to encourage increasing water consumption of drinking at least 8 glasses daily. Also she needs to be undergoing regular assessments and tests Jarvis, 2016.
C.W states she began her menstruation at the age of 12 years old. She further says that her LNMP is 1/11/2017. She has regular menstrual cycle of 28 days and usually lats for 5 days. Her menstrual discharge is usually heavy. Her last date of menstrual cycle was on 15/11/2017. The patient denies signs of menopause and she currently uses no contraception. She denies having any premenstrual pain and itching often accompanying menstrual cycle.
Health promotion plan s to encourage the patient on regular annual pap test for any signs of cancerative cells. This will be key in ensuring that she is advices regularly on healthy reproductive status.
Health Promotion
The patient denies any signs and symptoms of joints stiffness, fractures, deformities or any pain. She claims she doesn’t have any signs of knee pain, or spinal cord problems. She also denies an y history of seizures, paralysis or any form of numbness, memory loss or any form of nervousneous. Her endocrine health shows negative results the patient, denies any signs of appetite or polyruia, diabetes and hormone replacement therapy. Health promotion plan is to educate the patient on regular physical exercises, and having healthy balanced diet with heavy and regular intake of water daily. Further for good endocrine and hormonal balance health, is to encourage the patient for normal balance of fruits and vegetables to keep her body healthy and free from disease.
The patient further denies any form of harmful destruction on herself or others. She has not had any thoughts of depression and suicidal attempts. She claims that se is in peace with her friends and family who offer family support.
Health promotion plan is encourage her to always be open to friends when feeling of depression sets in. as this decreases the level of stress and depression.
C.W denies any form of swelling of lymph nodes and blood transfusions. She has no history of bleeding and mucous membranes, health promotion for the patient is educate on health skin check and always seek medical help when there are signs of bruising.
The functional status of the patient shows that she has good self esteem and self concept. She has attained a diploma level education ad she completed successfully she happy with hers scores of getting AA degree. She has a wonderful career as a vocational nurse. She aims at getting a bachelor degree in nursing.
Her financial state is that she has adequate income. Her source of income is in medical insurance. The patient states that she ascribes to Christian values and beliefs. This are essential in maintain a positive lifestyle. She has positive self care behaviors which she thinks keeps her on the right track of medical care.
C.W states that she always have a normal busy day with work and during home chores. She don’t perform any physical exercise and her normal life is characterized by busy life and performance of her normal duties.
The patient states that she normally takes care of all her activities of daily life and she helps her children prepare for school and performances of the normal daily chores.
Head
C.W states that she has limited time for leisure activities. She likes watching at her free time and taking nature walks. However with her busy schedule she claims that doesn’t have enough time for the leisure activities.
C.W states that she rarely prepares her food at home when not at work and often dislikes preparing food in the house. A 24 hr recall on her nutritional management indicates that she consumes high among snack foods food from outside outlets.
Prior to the medication protocol, she states that she normally buys food from outside and she prepares food just in the evening and most of times she buys food from outside and brings them to house for minimal preparation. Her weight status indicates she is lightly overweight with BMI index of 25.1. This is due to high snacking and regular consumption of meals.
C.W states that she normally has normal cordial relationships with her children. She states that she often is in good cordial relation with her family and she is a member of church choir. She sometimes spends time with church members and her peers at work place during weekends when not at work. She has not had any stressful event in her life of late. She maintains good relation with friends.
C.W states that she has been usual calm life, except when there is small family stress of children. She states that at times more finances are needed for upkeep of her children. However she states that she has leant on how to keep up with stress. She says when feeling stressed up always goes to church to join choir practices. She has observed that this way she can keep stress away.
C.W states that she normally takes coffee and chocolate in order to make her alert and always not dull. She denies having smoke cigarette or even smokes. Further she also denies having any alcohol use over the last 10 years. As mother she does not indulge in drug abuse or any form of drug abuse. With history of her family she doesn’t have any kind of history of drug abuse in the family. There is no form of depression and disruptive family patterns observed at home or at her family in general.
C.W states that she is always aware of environmental hazards around her environment and household. She stays in environmental friendly environment. She always keeps her house always clean and safe. Her dust bin is far end of the house aimed at minimization contamination of germs within the household. She says she often encounters various health hazards as a vocational health nurse. She often tries to minimize environmental hazards exposure for her and her family.
C.W states that she has not been a victim of gender based violence in her marriage life. She states that she is comfortable with her marriage life and bringing up the children, however the marriage life did not clearly come out.
She states that she is always concern of occupation health status of her job. She says that her job is always occasioned with various risks which need attention. At times she exposes herself to harm and infection due to the nature of her career. However she states that she has put in place enough measures to adopt a healthy work place schedule and coping with occupational hazards.
C.W states that her own health physical, spiritual and mental health is of sound state. She tries much to keep and maintain healthy weight gain. She states that she has no history of medical illness except for gall bladder, allergy medication and the C-section operation many years back. She is upkeep of her career and enjoys being and registered licensed vocational nurse. She has no concerns of care being given but alert on medication o be give. She is concern of how she consumes food regularly without such symptoms but now it has occurred. She states that her health goal is achieve healthy weight gain and consume healthy foods, however she has been having challenges meeting this as she occasionally buys foods from outside. Her participation in church activities is meant to keep her social and personal relation with God and church members positive.
References
Cunningham FG, et al. (2010). Cesarean delivery and peripartum hysterectomy. In Williams Obstetrics, 23rd ed., pp. 544-564. New York: McGraw-Hill.
Jarvis, C. (2016). Physical examination and health assessment (7th ed.). St. Louis, MO: Mosby Elsevier
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