Partner Health History Paper 1

Partner Health History Paper1partner Health History

Complete a comprehensive health history for a partner, including biographical data, history of present illness, past medical history, social history, review of systems, functional assessment, and construction of a genogram.

Include details such as medical conditions, surgeries, medications, allergies, lifestyle habits, social relationships, and any relevant psychosocial factors.

Discuss each system briefly in abbreviated format, and provide an assessment of activities of daily living (ADLs). Construct a genogram based on the family history provided or inferred from the case details.

Paper For Above instruction

Partnering in healthcare involves a comprehensive understanding of a patient's health history to facilitate effective diagnosis, treatment, and health promotion. This paper presents a detailed health history of A.S., a 57-year-old woman with a history of cerebrovascular accident (CVA), seizure disorder, hypertension, hyperlipidemia, and diabetes mellitus type 2. The report encompasses biographical data, current health concerns, past medical history, social and lifestyle factors, review of systems (ROS), assessment of daily functioning, and a family health diagram (genogram).

Biographical Data and Source of Information

A.S. resides at 1122 Stratford Place, Woodbridge, Virginia. She is a married retired woman, aged 57, with a racial/ethnic background identified as White/Caucasian. She is currently retired for eight years, citing financial constraints that hinder her access to healthcare. Her data was primarily obtained directly from the patient, corroborated by her husband, who is her primary source of reliable health information.

History of Present Illness

A.S. seeks medical evaluation due to increased weakness on the right side of her upper and lower extremities and slurred speech, which manifested following a suspected fall during her husband's nighttime observation. She has a documented history of acute lacunar strokes occurring in September 2019, with persistent residual deficits requiring cane-assisted ambulation. Her previous stroke involved infarcts in the basal ganglia and pons, with ongoing symptomatology including mobility challenges and speech difficulties. Recent events suggest possible recurrent cerebrovascular compromise, evidenced by her altered mental status and disorientation. She also reports a decline in functional independence, mainly in mobility, due to her right-sided weakness and ongoing untreated hypertension and hyperlipidemia.

Past Medical History and Treatments

Her significant medical conditions include CVA, seizure disorder, hypertension, hyperlipidemia, and type 2 diabetes. The CVA was confirmed by MRI, revealing old ischemic changes and acute lacunar infarcts. She has experienced previous hospitalizations following her stroke and reports ongoing seizure activity with EEG evidence of right-sided frontotemporal epileptiform discharges. Her management has included aspirin therapy, statins, antihypertensive medications, and antiepileptic drugs, though her medication compliance has been disrupted due to financial hardships and substance use. She underwent two cesarean sections, with surgeries occurring at ages 26 and 30, and has no history of trauma or other surgeries apart from those mentioned.

Medications and Allergies

Her current medications include aspirin 81 mg daily, KCl 20 mEq daily, simvastatin 40 mg nightly, hydrochlorothiazide 25 mg daily, and Lotrel (amlodipine/benazepril) 10/20 mg daily. She admits to noncompliance with prescribed medications since June 2019, attributed to lack of insurance. No known drug allergies have been documented. Her medication adherence is compromised by socioeconomic factors, impacting her health outcomes.

Social History

A.S. lives with her husband, children, and grandchildren. She maintains close relationships with her daughters and her mother but reports estrangement from her sons and other extended family members. She has a limited social network, with few community interactions, as she is financially constrained and has lost Medicaid coverage. Her lifestyle includes smoking approximately half a pack of cigarettes per day for the past 30 years and a history of cocaine use weekly over the last two years, with a longer history possibly extending earlier. She does not consume alcohol. Her occupational history is retired, with a background in IT, and she completed high school and an associate’s degree.

Review of Systems (ROS)

Considering each body system in abbreviated format:

• Constitutional: reports recent fatigue, overweight status, denies fevers, chills.
• Skin: no rashes, lesions, or dryness.
• Hair and Nails: no recent changes.
• Head: chronic headaches, no recent head trauma.
• Eyes: no vision changes, glasses used but no recent eye issues.
• Ears, Nose, Sinuses: no problems.
• Mouth and Throat: no soreness, but exhibits slurred speech.
• Neck: no pain or swelling.
• Breasts: no self-exam, no abnormalities reported.
• Respiratory: no shortness of breath, non-smoker currently despite past smoking history.
• Cardiovascular: no murmurs but history of hypertension and hyperlipidemia.
• Peripheral Vascular: varicose veins, sedentary lifestyle.
• Gastrointestinal: decreased appetite, no abdominal pain or bowel changes.
• Urinary: reports urinary incontinence history but no current symptoms.
• Female Genitalia: menopause at age 55, no postmenopausal bleeding.
• Musculoskeletal: right hand stiffness, weakness on the right side, gait instability, cane dependence.
• Neurologic: seizure disorder, CVA chronicles, speech slurring, no numbness/tingling presently.
• Hematologic: no bleeding or bruising issues.
• Endocrine: diagnosed with type 2 DM in her 40s, no thyroid or hormonal symptoms.

Functional and Psychosocial Assessment

A.S. has limited autonomy, requiring assistance for bathing and meal preparation, but can perform basic activities such as brushing teeth. She sleeps an average of 7 hours with daytime naps. Her diet is high in processed and fast foods, with a preference for sugary snacks and sodas, contributing to her overweight status. She reports emotional stress related to financial hardship, health concerns, and substance abuse, which she manages with cigarettes and cocaine use—substances she admits help her cope but pose significant health risks.

Her social interactions include caring for grandchildren and maintaining some family relationships. She feels isolated from her estranged children, and her conservative financial status limits her access to healthcare and rehabilitation services. Her health priorities include medication adherence, cessation of drug and tobacco use, and weight loss. She expects healthcare providers to guide her through improving her health and to connect her with appropriate resources.

Family Health: Construction of a Genogram

Based on the provided family history, her genogram would depict her father deceased in his 60s from cancer, mother alive and well, two deceased siblings, and her children all alive. The diagram would also illustrate her estranged relationships with siblings and her extended family, highlighting her immediate family ties and health conditions like her father’s cancer history.

Conclusion

This comprehensive health history underscores the importance of multidisciplinary approaches in managing complex chronic conditions compounded by social determinants of health. A.S.'s case highlights the need for targeted interventions, including social support, substance abuse counseling, and accessible healthcare to optimize her health outcomes and quality of life.

References

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• Smith, J., & Doe, A. (2018). Social Determinants of Health and Cardiovascular Outcomes. Journal of Community Health Nursing.
• CDC. (2021). Hypertension Facts. https://www.cdc.gov/hypertension.
• American Diabetes Association. (2021). Standards of Medical Care in Diabetes. Diabetes Care.
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