Milestone #2

BIOGRAPHICAL DATA (10 pts)

Date:

5/22/16

Initials:

LM

Age:

45 years old

Date of birth:

4/10/1971

Birthplace:

Puerto Rico

Gender:

Female

Marital status:

Married

Race:

Hispanic, Latino

Religion:

Baptist

Occupation:

Head Manager of Accounting Department

Health insurance:

Does not want to disclose

Source of information:

Patient herself

Reliability of source of information:

Patient seems reliable, keeps answering the same questions without changing the previous answer.

PRESENT HEALTH HISTORY/ILLNESS (15 pts)

Reason for seeking care:

“ Started feeling left arm,shoulder numbness today at work, my blood sugar was elevated”

Health patterns:

Does not want to disclose

Health goals:

HA1c bellow 6 , lose 30 pounds,

HEALTH BELIEFS AND PRACTICES (15 pts)

Beliefs and practices:

Patient does not follow a healthy diabetic diet

Factors influencing healthcare decisions:

Stress at work,long working hours without eating a proper diet, depression, low self-esteem, mother of five children . Going to school for her Master Degree.

Related traits, habits or acts:

Obesity, feels overwhelmed, eats fast food everyday

MEDICATIONS (15 pts) (Please refer to your assignment guidelines.)

Prescription medications:

Metformin 500mg BID

Aspirin 325mg Daily

Zocor 10mg Daily

Over-the-counter medications:

Tylenol

Herbals:

Melatonin

PAST HISTORY (15 pts)

Childhood diseases:

Varicella, Chicken pox

Immunizations:

Does not remember

Allergies:

NKA

Blood transfusions:

One 10 years ago

Major illnesses:

Diabetes type 2

Injuries:

Car accident two weeks ago, no major injury.

Hospitalizations:

First time

Labor and deliveries:

Grav 5, Term 3, Preterm 2, Ab 0, Living 5

Surgeries:

Appendectomy, 2 C-sections

Use of alcohol:

Occasionally

Use of tobacco:

Denies

Use of illicit drugs:

Denies

EMOTIONAL HISTORY (15 pts)

Mental, emotional or psychiatric problems:

Depression

FAMILY HISTORY (15 pts)

Father:

Tobacco smoker, died from stroke 3 years ago

Mother:

Diabetes type 2

Siblings:

Cancer, Diabetes, Hypothyroidism

Grandparents:

Alzheimer, MI, Suicide

PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts)

Occupational history:

Sales Representative, Accounting ,

Educational level:

Associated Degree

Financial background:

Employee

ROLES AND RELATIONSHIPS (15 pts)

Significant others:

Husband

Support systems:

Family

ETHNICITY AND CULTURE (10 pts)

Ethnicity and culture:

Music, Art, Dance, Traditions

Physical and social characteristics that influence healthcare decisions:

Sedentary lifestyle , Obesity

SPIRITUALITY (5 pts)

Religious and spiritual needs:

Improve self-esteem .

SELF-CONCEPT (5 pts)

View of self-worth:

She does not feel good about the way she physically looks

Future plans:

Exercise, get more information on Diabetes management and diet, lose weight.

REVIEW OF SYSTEMS (20 pts) (Please refer to your assignment guidelines and chapter 4 of your text. This is NOT a physical assessment.)

Skin, hair, nails:

Normal for ethnicity, warm, brittleness nails

Head, neck, related lymphatics:

Frequent headaches, dizziness

Eyes:

Decreased vision , wear glasses

Ears, nose, mouth, and throat:

Increase Thirst

Respiratory:

Denies cough, chest pain or shortness of breath

Breasts and axillae:

Pain to the back due to breast are too big.

Cardiovascular:

Dyspnea at night , Anemia

Peripheral vascular:

Swelling of legs at night after working for long hours

Abdomen:

Abdominal pain, constipation

Urinary:

Awakens up to 3 times to urinate at night

Reproductive:

Last menstrual period 4/13/16

Musculoskeletal:

Generalized weakness, back pain

Neurologic:

Left arm numbness