Patient’s Health History and Screening
The best way to predict any future behaviour is to have a look at past practices. Historical data provides a comprehensive report on a patient or the patient’s family health history. Its purpose is to come up with a plan that promotes health and deals with a patient’s current health issues according to Wilson & Giddens, (2013). In this text, we shall have a look at an adolescent’s health history and screening. Particular data on the family history shall also be considered.
In this case, we have a patient born in the year 1999 July 21st. The patient is a young Caucasian female who claims to be in a relatively stable condition despite having hypertension. The subject lives with the parents and is currently studying. The subject is a mother of one who is in good health. The patient started showing hypertensive symptoms at the age of 17. With regards to the mental state, the patient was considered fit as per research was done by Santos VG, (2005).
The patient has a long history of hypertension that was controlled by diuretic therapy. Upon complaining about intermittent midsternal chest pain, the patient was admitted to CPMC. The electrocardiogram at the time indicated a first-degree atrioventricular block, and a chest X-ray showed mild pulmonary congestion, with cardiomegaly. Myocardial infarction was lined out due to no electrocardiographic and cardiac enzyme irregularities. The patient was released after a short stay and was placed on treatment which included enalapril, lasix, and digoxin, for supposed congestive heart failure. From then on her cardiologist has been keeping a close eye on her.
Aside from hypertension, the patient denies any form of coronary artery disease factors like diabetes or family history of heart disease. On prolonged standing, the patient has complained of mild ankle oedema and denies experiencing recent chest pains. On the night before being admitted, the patient complained of onset of throbbing pain below the breastbone as she was watching television. In accordance to a research done by Blake, D., Farquhar, C., Johnson, N., & Proctor, M. (2007) the pain could have been brought about by the patient’s current condition. The pain was compared to that of a toothache and was relentless. However, there were no signs of vomiting, palpitations or dizziness. After taking two tables spoon of antacid, the patient managed to get some sleep.
In the morning the patient woke up pain-free but when she went to the bathroom, the pain came back and was more intense. At this point, the patient called to her mother who gave her an aspirin and rushed her to the emergency room. The electrocardiogram on appearance indicated sinus tachycardia at 110, with noticeable ST increase in leads I, AVL, V4-V6 and intermittent ventricular paroxysmal reductions. The patient without delay was given thrombolytic therapy and cardiac tablets and was then taken to the intensive care unit.
Family Health History
A family health history can lend a hand in identifying if one is at higher risk for certain conditions majorly because of shared genes and behaviours. In case there is a risk a doctor can then recommend proper lifestyle changes that will either slow or delete chances of being affected by a particular condition. Whereas there may be a high incidence of a specific disease in a family, it does not necessarily mean that one will undoubtedly develop that condition. The patient was brought up by a mother as the father died at the age of 30 from kidney failure. The patient had an elder brother who died at the age of 23 due to pneumonia. The subject also has a 1-year-old son who is in good health. Both the grandparent’s from the mother’s side suffered from diabetes and hypertension which they succumbed to after ten years. Though their diagnosis did not mean that it would run in the family states Courties, A., & Sellam, J. (2016). On the father’s side, there was a history of asthma and lung cancer though only distant relatives had contracted the disease. There has been no known illness relating to bones like arthritis, and also there is no record of anyone having any other type of cancer other than that of the lung. In general, they all have had their debuts with illness, but except for the brother all have lived beyond 60 years.
The review of policies or symptoms is a listing of inquiries, prearranged by organ system, intended to expose dysfunction and ailments. There we no complaints of headache change in vision, nose or ear, or a sore throat. The patient stated that there were mild chest pains which could quickly be relieved by the use of painkillers. Gastrointestinal: No complaints of dysphagia, queasiness, vomiting, or alteration in her stool pattern with regards to consistency or colour. Approximately three times a month the patient complained of bouts of epigastric pain and burning in quality. No Genitourinary grievances like nocturia, polyuria or vaginal bleeding arose. Considering the patient’s musculoskeletal structure all was in check as she did not complain of any back pins even when gardening. The neurological condition is also next to being perfect as she has no problem with numbness, weakness or in coordination. A plan was then developed to help reduce the possibility of diabetes which was gotten from a research article from Shin, J. J., Lee, E. K., Park, T. J., & Kim, W. (2015)
Review of Symptoms and Diagnosis
Majorly the health review system sought to find out the state of the body parts and their functioning. They entail a study on the operation of the ENT, ear nose and throat. Cardiovascular which dealt with heart mainly, respiratory which established breathing patterns. For the cardiovascular conditions it would be easily controlled according to Corey, B.L., & Stahl, R.D. (2017). Gastrointestinal, neurological, musculoskeletal and integumentary were also the major areas to be looked into.
It is a tool for individualising patient care. According to the patient’s assessment, the patient was suffering from hypertension and had some forms of mild pains in her bones. On wellness, it was determined that the patient was recuperating well enough due to young age. There are very many risk factors associated with the patient, but according to the diagnosis, if the patient adhered to a strict treatment system, there was a high chance of living a good life. According to Hailey D, Tran K, Dales R, Mensinkai S, McGahan L. (2001) also having enough sleep would significantly change the effects of hypertension.
There was a significant reason as to why the patient was put on medication based on the nurse’s assessment. Hypertension which was possessed by the patient needed certain kind of drugs which were well prescribed and given. This medication was set on seeing to the wellness of the patient and reducing all the risks whether foreseeable or not. For each diagnosis given there was a remedy and if followed would allow the patient to lead a healthy and healthy life. A system according to Whooley MA, Kip KE, Cauley JA, Ensrud KE, Nevitt MC, Browner WS, 2003, which would help the subject cope with depression issues.
After this comprehensive report, the medical team came up with a proper way to address the patient’s condition. One was to continue with certain drugs like aspirin, heparin beta blockers and nasal oxygen. Furthermore due to having some form of stress antidepressants were used to aid in the stress as stated by Armitage R,(2001). A detailed series of physical exams and lab reports routine would also be enforced. To assess post-MI heart function, an echocardiogram would also be obtained. Consequently, the patient will also need to start early on the beta blocker therapy which would preserve the LV ejection fraction. The blood pressure and the ACE inhibitor would also need to continue and do on a regular basis. As the patient is afebrile and without costovertebral tenderness, it would also be required to have pyuria. For the case of urinary infection, Bactrim treatment and follow up on urine culture result would highly come in recommended. Adherence to this treatment plan will not only ease the pain but also ensure a semblance of peace and some form of a healthy life. Additionally, it would also significantly improve her physical condition and reduce risk factors that had been previously assessed.
In conclusion, the patient suffered from hypertension and had some form of pains. While there has been no form of permanent solution to hypertension treatment was carefully formulated which would aid the patient significantly. A comprehensive test was done with regards to health, and a reasonable solution was made to ensure a healthy life.
References
American Academy of Sleep Medicine. International Classification of Sleep Disorders, Revised: Diagnostic and Coding Manual. American ARocha FL, Hara C, Rodrigues CV, Costa MA, e Costa EC, Fuzikawa C,(2003).
Armitage R. The effects of antidepressants on sleep in patients with depression. Can J Psychiatry. 2000;45:803–809. [PubMed]
Blake, D., Farquhar, C., Johnson, N., & Proctor, M. (2007). Cleavage stage versus blastocyst stage embryo transfer in assisted conception. Cochrane Database of Systematic Reviews, 2007(4).
Corey, B.L., & Stahl, R.D. (2017). Glycemic control and cardiovascular disease risk reduction after bariatric surgery. In J. l. Cameron (Ed.), Current surgical therapy (pp. 806-811).
Courties, A., & Sellam, J. (2016). Osteoarthritis and type 2 diabetes mellitus: What are the links? Diabetes Research and Clinical Practice, 122, 198-206.
Hailey D, Tran K, Dales R, Mensinkai S, McGahan L. Recommendations and supporting evidence in guidelines for referral of patients to sleep laboratories. Sleep Med Rev 2006;10:287-299.cademy of Sleep Medicine, Rochester, Minnesota, 2001.
Santos VG. Is insomnia a marker for psychiatric disorders in general hospitals? Sleep Med 2005;6:549-553.
Sateia M, Doghramji K, Hauri PJ, Morin CM. Evaluation of chronic insomnia. Sleep 2000;23:1-66.
Shin, J. J., Lee, E. K., Park, T. J., & Kim, W. (2015). Damage-associated molecular patterns and their pathological relevance in diabetes mellitus. Ageing Research Reviews, 24(Pt A), 66-76. doi:10.1016/j.arr.2015.06.004
Whooley MA, Kip KE, Cauley JA, Ensrud KE, Nevitt MC, Browner WS. Depression, falls, and risk of fracture in older women. Study of Osteoporotic Fractures Research Group. Arch Intern Med. 1999;159:484–490. [PubMed]
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