week 1

1

History Video and Risk Assessment

RN, BSN

United States University

MSN 572- Advanced Health and Physical Assessment Across the Lifespan

Dr. O

May 10, 2021

This study source was downloaded by 100000783599662 from CourseHero.com on 08-30-2021 23:24:08 GMT -05:00

https://www.coursehero.com/file/99809470/Health-History-wk-1docx/

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SOAP

Video link

https://studio.youtube.com/video/YV5L-FnZwNQ/edit

SUBJECTIVE:

ID:

B.G. age 32, Hispanic male, DOB 06/11/1988. Presents to the clinic for a wellness check per job. Came to clinical by himself. He currently resides with his girlfriend. The patient’s last wellness exam was in 2019. Not sure of specific dates. He has no current complaints.

CC: “A wellness check.”

HISTORY OF PRESENT ILLNESS (HPI):

34-year-old male presents to the clinic for a wellness exam and states he healthy. His last exam was in 2019. He is up to date on his immunizations and flu shot 9/2020 and COVI-19 vaccine x2 2/2020. Denies any prescription use. Last dental exam in 2019 for routine cleaning. Uses glasses with a previous eye exam in 2019. No eye prescription changes on the visit. He denies any complaints or concerns at this time. The patient presents as a reliable historian.

PAST MEDICAL HISTORY

Denies past medical problems

PAST MEDICAL PROCEDURES

Tonsillectomy at nine years old on 03/03/2000

MEDICATIONS

Claritin- seasonal allergies PRN

Men’s Gummy Multivitamin- daily

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https://www.coursehero.com/file/99809470/Health-History-wk-1docx/

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ALLERGIES

Seasonal allergies- pollen. Seasonal

Food- denies food allergies

Medications- denies

LMP (as applies)

N/A

FAMILY HISTORY

Mother- 50 yr. old female who is healthy with no medical problems

Father- 51 yr. old male who is healthy with no medical problems

Brother- 26 yr. old male who is healthy with no medical problems

Sister- 27 yrs old female who is healthy with no medical history.

Maternal grandmother- in the 80’s. no medical history

Maternal grandfather- in the ’90s has a history of emphysema and COPD from cigarette smoking

Paternal grandmother- 80’s, has a history of D.M.- insulin-dependent

Paternal grandfather- unknown

SOCIAL HISTORY

-SEXUAL/REPRODUCTIVE- reports in a monogamous relationship for the last three years with a female. Denies use of contraceptives. Partner is on birth control

-TOBACCO USE/Vaping: pt denies smoking and vaping. Denies being around people who smoke

-ALCOHOL USE: social- 2-3 beers a week.

-DRUG USE: denies illicit drugs. Denies being around people who use drugs

-MARITAL HISTORY: not married, 3-year long relationship with a girlfriend. Lives with girlfriend in a home that is owned

-OCCUPATION: Emergency room director a Banner Health Hospital

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https://www.coursehero.com/file/99809470/Health-History-wk-1docx/

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-EXERCISE/DIET: Does cross-fit three times a week. Meal prep with high protein diet Pt denies eating red meat. Eats lean white meat. Chicken preferred—insufficient vegetable intake. Pt eats 2-3 servings of fruit a day. Drinks1 gallon of water a day.

-SLEEP/STRESS: sleeps an average of 7-8 hours a night. Pt reports no difficulties falling asleep. Pt feels rested and not tired throughout the day.

IMMUNIZATIONS

Up to date immunizations. Flu vaccine on 09/2020 and is fully Covid-19 vaccinated with a second dose given on 02/2021

SPIRITUAL AFFILIATION

Pt states he is Catholic. Pt is active with the church community attending Sunday mass weekly via skype.

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies weight changes or decreased appetite.

EYES: he has had glasses since pt was nine years old. The last eye exam was two years ago. Denies redness or drainage—previous eye exam in 2019.

EARS, NOSE, MOUTH/THROAT: denies hearing loss, discharge, and earache, reports rhinorrhea, sneezing, stuffiness during seasonal allergies, denies pain or difficulty swallowing. Last dental exam two years ago. 2019.

CARDIOVASCULAR denies angina, palpitations, and dyspnea

RESPIRATORY: Denies wheezing and shortness of breath; pt reports deny dry cough with allergies cough and denies sputum production.

GASTROINTESTINAL: denies dysphagia, constipation, diarrhea, and abdominal pain, denies rectal or history colon cancer. Denies having a colonoscopy. Daily B.M., soft brown stools

GENITOURINARY: denies scrotal pain, nocturia, urinary urgency or frequency, incontinence, libido changes, Denies scrotal pain, weak stream, or erectile dysfunction

MUSCULOSKELETAL joint pain, joint swelling, muscle pain.

INTEGUMENTARY/BREAST: Denies eczema, excessive dryness, and discoloration. Denies breast pain.

This study source was downloaded by 100000783599662 from CourseHero.com on 08-30-2021 23:24:08 GMT -05:00

https://www.coursehero.com/file/99809470/Health-History-wk-1docx/

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NEURO: denies seizures, headaches, memory loss

PSYCH: denies anxiety, depression, psychosis, bipolar

ENDOCRINE: Denies heat or cold intolerance, weight changes, libido, or sexual performance

HEMATOLOGIC/LYMPHATIC: Denies easy bruising, anemia

ALLERGY/IMMUNOLOGY: Denies drug/food/ allergies, environmental allergies pollen

OBJECTIVE:

Ht : 5’10” Wt. : 210 BMI: 30.1

RISK ASSESSMENT:

1) Risk of diabetes due to BMI 30.1 and paternal grandmother is a diabetic and insulin-

dependent. Overweight and especially obesity, particularly at younger ages, substantially

increases the lifetime risk of diagnosed diabetes, while their impact on diabetes risk, life

expectancy, and diabetes duration diminishes with age (Narayan et al., 2007). Even a

moderate elevated BMI is associated with an increased risk of developing D.M.

complications (Gray et al., 2015).

2) Risk for depression- healthcare workers in acute care due to the COVID-19 pandemic.

Healthcare workers, who are at the forefront of the fight against COVID-19, are

particularly susceptible to physical and mental health consequences such as anxiety and

depression (Sahebi et al., 2021).

3) Risk of nutritional deficiency- due to not eating vegetables. Sufficient intake of fruits and

vegetables has been associated with a reduced risk of chronic diseases and body weight

management, but the exact mechanism is unknown (Pem & Jeewon, 2015). Eating

vegetables provides health benefits- people who eat more vegetables and fruits are part of

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an overall healthy diet are likely to have a reduced risk of some chronic disease

(Vegetables | MyPlate, 2020).

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https://www.coursehero.com/file/99809470/Health-History-wk-1docx/

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References

Gray, N., Picone, G., Sloan, F., & Yashkin, A. (2015). Relation between BMI and Diabetes

Mellitus and Its Complications among US Older Adults. Southern Medical Journal,

108(1), 29–36. https://doi.org/10.14423/smj.0000000000000214

Narayan, K. M. V., Boyle, J. P., Thompson, T. J., Gregg, E. W., & Williamson, D. F. (2007).

Effect of BMI on Lifetime Risk for Diabetes in the U.S. Diabetes Care, 30(6), 1562–

1566. https://doi.org/10.2337/dc06-2544

Pem, D., & Jeewon, R. (2015). Fruit and Vegetable Intake: Benefits and Progress of Nutrition

Education Interventions- Narrative Review Article. Iranian Journal of Public Health,

44(10), 1309–1321. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4644575/

Sahebi, A., Nejati-Zarnaqi, B., Moayedi, S., Yousefi, K., Torres, M., & Golitaleb, M. (2021). The

prevalence of anxiety and depression among healthcare workers during the COVID-19

pandemic: An umbrella review of meta-analyses. Progress in Neuro-

Psychopharmacology and Biological Psychiatry, 107, 110247.

https://doi.org/10.1016/j.pnpbp.2021.110247

Vegetables | MyPlate. (2020). Myplate.gov. https://www.myplate.gov/eat-healthy/vegetables

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