Task:
Task #1 Please do an essay documenting the health history which is the data that is below.
Task #2 please do a ONE PAGE ESSAY OF THE REFLECTIVE EXPERIENCE OF THE INTERVIEW. EVERYTHING NEED TO BE BASED OF WHAT IM GOING TO SEND YO. THE HEALTH HISTORY.
Health History
A. Health History Interview
Background:
Initials: V. D
Age: 30
Gender: Female
Height: 5’7
Weight: 136 lbs. 60 kg
Religion: Catholic
Health Problems: NONE
Current Treatment:
She is used Melatonin every day before going to bed. The quantity varies between 3 to 5 gummies. Also, any muscle relaxant.
In addition, 1 tablet of Sedoxil, depends if she feels with anxiety.
Past Treatment: None
Current Medications (Prescription, OTC, Herbal): Sedoxil
OTC Medications:
Vitamin C
Collagen
Multivitamin
Melatonin
Past Medications (Prescription, OTC, Herbal): N/A
Family Health History:
Father’s Side Grandfather: Cardiovascular Problems / heart failure/ Deceased in 1996.
Father’s Side Grandmother: None
Mother’s Side Grandfather: Cardiovascular Problems. Undergoing an open-heart surgery.
Mother’s Side Grandmother: None
Father: N/A; 56 years old
Mother: Cardiovascular problems. Also, presents elevation of cholesterol. 55 years old
Aunts: None
Uncles: None
Sister: None
Current Lifestyle Practices & ADL’s:
Diet: Balance diet, mostly healthy. However, low intake of water.
Activity: Training every day. Also, practice pole dance class.
Sleep Pattern: 5- 4 hours per night. No naps between
Elimination Patterns: Urinates 3 to 4 times daily. Regarding bowel elimination is one or two times per day.
Alcohol consumption: none
Recreational Drug Use/Smoking: none
Annual Physical Examination: Completed in 2019- doesn’t remember the month-, no complications
Dental Care: Last visit February 2021, no complications
Last GYN exam: February 2021 – No complications
Health Habits:
Exercise her body constantly
Cooks her meals at home
Have a great consumption of vegetables and fruits
Low intake of sodium as well as low fat dairy products
No consumption of alcohol
Chief Complaint:
Pt. stated, “I believe that I started to experience anxiety at night because I can barely sleep”.
Occupation:
Singer and stomatology
Current Health Concerns:
Pt. stated, “I feel my brain full of thoughts and it does not let me sleep at night”
Pt. stated, “Melatonin gummies no longer work for me even though I am getting more than before.”
How patient addresses concerns:
Used her phone till he falls asleep
Initiated intake of Sedoxil
What patient would like to improve of overall health:
Patient state: “She would like to rest 7 hours or more since it is causing her problems in her daily activities. “