Health Assessment lab manual

Sample Solution

  The patient is a 55-year-old female who presents with a chief complaint of fatigue. She has been feeling tired for the past few months, and she feels like she is not able to do as much as she used to. She also reports having difficulty sleeping and feeling forgetful.

Full Answer Section

  Past Medical History

• Hypertension: The patient has been diagnosed with hypertension for 10 years. She is currently taking lisinopril 10 mg daily.
• Hyperlipidemia: The patient has been diagnosed with hyperlipidemia for 5 years. She is currently taking atorvastatin 20 mg daily.
• Obesity: The patient has been overweight or obese for most of her adult life. She currently has a BMI of 30.
• Heart disease: The patient's father died of a heart attack at the age of 50.
• Stroke: The patient's grandmother had a stroke at the age of 70.

Family History The patient's family history is significant for heart disease and stroke. Her father died of a heart attack at the age of 50, and her grandmother had a stroke at the age of 70. Review of Systems The patient's review of systems is positive for fatigue, difficulty sleeping, and forgetfulness. She denies any other symptoms. Conclusion The patient is a 55-year-old female who presents with fatigue, difficulty sleeping, and forgetfulness. Her past medical history is significant for hypertension, hyperlipidemia, and obesity. Her family history is significant for heart disease and stroke. The review of systems is positive for fatigue, difficulty sleeping, and forgetfulness. Was the person willing to share the information? If they were not, what did you do to encourage them? The patient was very willing to share the information. She was open and honest about her health history, and she was eager to learn more about her symptoms. Was there any part of the interview that was more challenging? If so, what part and how did you deal with it? The most challenging part of the interview was when I asked the patient about her family history. She became tearful when she talked about her father's death, and I had to be patient and allow her to take her time. How comfortable were you taking a health history? I was very comfortable taking a health history. I felt confident in my ability to ask the right questions, and I was able to build rapport with the patient. Overall, I felt that the health history went well. The patient was very cooperative, and I was able to gather a lot of valuable information. I am confident that this information will be helpful in making a diagnosis and developing a treatment plan.