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MN552 Advanced Health Assessment Help

Please select a volunteer friend or family member to interview and gather data to complete this Assignment.

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Introduction

Health assessment is the first step in health care initiation. An accurate health assessment is very much needed to design and develop a decent health care plan. The accuracy of the subjective data collected and the analysis of the same will decide the quality of the final outcomes in any organization in general. The following part of the discussion is about the advanced health assessment of a selected individual and interviewing the same(Forbes,2015). Further the work consists in arranging the data collected well organized for developing a health history.  Further a Genogram is provided with the input data. Genogram is based on three generations of data only in this current presentation (Zubatsky, 2015).

Date of History/Interview:

1. Biographical Data:

a. Name: MC

b. Address: South street, Box No:123, California

c. Phone number: 00+1+xxx+xxxxx

d. Primary language: American English

e. Authorized Representative: Brother(Johnson)

f. Age and Date of Birth: 14 years, 21-8-2004

g. Place of Birth: California city

h. Gender: Female

i. Race: White(European Americans)

j. Marital status: Unmarried

k. Ethnic/Cultural origin: European Origin

l. Education: Purusing pre-university academics

m. Occupation: Student

n. Health insurance: Covered under father Insurance plans

2.Chief Complaint

a. Patient is suffering with chest pain – occasionally facing the problem from last few weeks

b. As of now she is suffering with serious pain difficulty from last two hours.

3. History of present illness:

Provocative or palliative: Unpredictable in nature, comes at both while activity as well at rest.

Quality or quantity:  An associated feeling of tightness and pressure

Region or Radiation: Jaw and neck often experience the spread of the pain from the chest area.

Severity: Can be rated at about 8 in the severity scale from 0 to 10 (10 for the most severe).

Timing: Comes and goes not always pains.

Understand patient perception of the problem: Patient perception is limited to the feeling of the pain in the chest.

It can be due to cardiac or non cardiac reasons.

- Non-cardiac reasons may include, Musculo-skeletal, pulmonary, gastrointestinal, and miscellaneous

- Cardiac reasons may include inflammatory, cardiatic abnormalities etc.

4. Past medical History:

a. Medical Hx:  No major illness during the life span, an Appendicitis surgery few years back.

b. Childhood illness: No major illness, only occasional illnesses due to fever and common cold.

c. Surgical procedures: Appendicitis surgery on 3/3/2015 – Inpatient for 2 days.

d. Obstetric: No Applicable

e. Immunizations:  Diptheria, Tetanus, Pertussis, Polio, Measles, Mumps, Rubella, Chicken pox, Hepatitis A and B, Influenza, Pneumococcal(PCV13)

f. Psychiatric Hx: No any psychiatric illness reported.

g. Allergies: No any allergies

h. Current medication: Taking herbal supplement for getting slim and to lose weight. Doses every day one pill before sleeping.

i. Last examination date: 1/5/2018

Routine medical checkup done last year April.

Physical normal  - Light obeseity

Eye exam   - Short sight (recommended lenses)

Foot exam  - Normal

Dental exam – Cavities – Recommended calcium supplements

Hearing screen - Normal

EKG - Normal

Chest X-ray - Normal

Pap Test - Normal

Mammogram - Normal

Serum cholesterol - Normal

Stool occult blood - Normal

PSA - Normal

UA - Normal

TB skin test - Normal

Sickle cell - Normal

PKU - Normal

Lead level - Normal

Hematocrit - Normal

5. Family History (genogram)

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