Perform a complete health history on a self-selected “patient”. For this assignment, you will need to identify a family member or friend as your selected patient for the entire assignment. No demographic or identifying information is to be shared for this assignment. Use chapter four of your Jarvis (2020) textbook as a guide to complete this paper.
Synthesize your findings in a narrative, scholarly paper format based on the directions below.
Structure and Content:
No more than six pages in length, double-spaced, not including the title and reference pages.
12 point font Times New Roman or 11 point font Calibri.
Title page in APA style.
Complete sentences in narrative format.
Sections of your Paper:
Introduction (no heading):
Briefly introduce your patient to the reader. Include biographic data, source of history, and present history or history of present illness.
Past Health:
Childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunizations, last examination date, allergies, and current medications.
Culture and Genetics:
Briefly highlight in the findings of the family history identified in the genogram discussion. Discuss any pertinent cultural issues.
Review of Systems:
Present a brief overview highlighting only abnormal findings.
Functional Assessment:
Use your Jarvis (2020) textbook as a guide. You may want to discuss self-esteem, self-concept, activity/exercise, nutrition/elimination, sleep/rest, spiritual resources, coping and stress management, personal habits, alcohol, illicit or street drugs, environmental/hazards, intimate partner violence, and occupational health.
Perception of Health:
Conclude with a summary of your patient’s perception of health. Identify their health concerns, goals, and expectations from their healthcare providers
Each section should be used as a Level 1 heading in your paper “Centered, Bold, Title Case Heading” (American Psychological Association, 2020, p. 48).
Please remember to protect your patient’s privacy.
Use initials instead of first and last names when mentioning your patient.
Do not disclose your patient’s address.
This is not a medical record, it is an academic paper so please follow APA 7 guidelines.SPACING:
For some reason, Word will often insert extra spacing between paragraphs. I will deduct points for this, so when you are done with your paper, highlight the content and check the spacing under the paragraph tab.
Introduction:
The patient for this health history is identified as MJ. She is a 45-year-old female and the source of history is her self-report. MJ is a stay-at-home mother of two children and resides in a suburban area. The reason for seeking medical attention is for a routine physical exam. She reports no acute symptoms but has some concerns about her overall health.
Past Health:
MJ reports a history of chickenpox during childhood. She has had no significant accidents or injuries. There is no history of chronic illness, hospitalization, or surgery. MJ has had two uncomplicated pregnancies and deliveries, and no history of miscarriages. She has received routine immunizations including tetanus, measles, mumps, and rubella. Her last examination was a year ago. She reports seasonal allergies and takes over-the-counter allergy medication as needed. Her current medications include a daily multivitamin, vitamin D supplement, and occasional use of ibuprofen for menstrual cramps.
Culture and Genetics:
MJ identifies as White and European-American. There is no known family history of chronic illnesses. However, her father had a heart attack in his 50s. MJ reports no significant cultural issues.
Review of Systems:
MJ reports occasional headaches and migraines, but no vision changes, hearing loss, or tinnitus. She has no difficulty breathing, but reports occasional shortness of breath with strenuous activity. She denies chest pain, palpitations, or syncope. She has no gastrointestinal symptoms but reports occasional heartburn. She reports no musculoskeletal pain, but experiences occasional joint stiffness. She has no urinary symptoms but reports occasional stress incontinence. She reports no skin changes or rashes.
Functional Assessment:
MJ reports good self-esteem and self-concept. She engages in regular exercise by taking daily walks and practicing yoga. Her diet consists of a variety of fruits, vegetables, and lean protein sources. She reports no issues with elimination or constipation. She reports a consistent sleep routine and gets 7-8 hours of sleep per night. MJ reports no religious affiliation but identifies as spiritual. She reports good coping skills and manages stress through exercise, meditation, and spending time with family and friends. She reports no use of tobacco, alcohol, or illicit drugs. She reports no environmental hazards in her home. She denies any history of intimate partner violence. She has no significant occupational health concerns.
Perception of Health:
MJ perceives her health to be good but has concerns about her risk for heart disease due to her father’s history. She has set a goal to increase her daily exercise routine and improve her diet to reduce her risk. She expects her healthcare providers to provide guidance and support in achieving her health goals.
Conclusion:
MJ presents as a healthy 45-year-old female with a past medical history that is largely unremarkable. She has no significant cultural issues, and her family history is negative for chronic illnesses. She reports occasional headaches and migraines but otherwise denies any significant abnormalities on review of systems. MJ engages in regular exercise, has a healthy diet, and good sleep habits. She reports good coping skills and stress management techniques. She is aware of her increased risk for heart disease and has set goals to improve her exercise and diet to reduce her risk. MJ expects her healthcare providers to support and guide her in achieving her health goals.
