Comprehensive Health Assessment Assignment Paper

Comprehensive Health Assessment Assignment Paper

Subjective Data

IDENTIFYING DATA

Date: 08/31/2023

Patient’s Name: JH

Date of Birth: 02/15/1975

Race: White

Patient Sex: Male

Occupation: IT Consultant

Insurance: Blue Cross Blue Shield

Age: 48 years

Informant: Patient

Reliability: Reliable, appears coherent and alert Comprehensive Health Assessment Assignment Paper

ORDER A PLAGIARISM-FREE PAPER HERE

CHIEF COMPLAINT: Headaches

History of Present Illness:

JH, a 48-year-old male, presents to the clinic today with complaints of persistent headaches. He describes the headaches as a throbbing pain on the left side of his head, which he rates as 7 out of 10 on the pain scale. He reports that these headaches have been occurring for the past three months, with increasing frequency and intensity. JH states that the pain is usually located behind his left eye and occasionally radiates to his left temple. He further notes that the headaches are often accompanied by photophobia and phonophobia, and he prefers to stay in a dark, quiet room during an episode. The headaches last for several hours and are not relieved by over-the-counter pain medications. He denies any aura, visual disturbances, or other neurological symptoms preceding the headache.

MEDICAL HISTORY

Allergies: No known drug allergies.

Immunizations: Up to date with childhood immunizations, last tetanus shot 2 years ago, no record of HPV vaccination.

Past Illnesses and Hospitalizations: JH reports a history of childhood asthma, which resolved in adolescence. He has had no recent illnesses requiring hospitalization.

Current Medications: None. JH mentions that he has been trying to manage his headaches with over-the-counter ibuprofen, but it provides minimal relief.

SURGICAL HISTORY: No prior surgeries.

INJURIES: No significant injuries reported. Comprehensive Health Assessment Assignment Paper

 

SOCIAL HISTORY AND FAMILY ASSESSMENT

Birthplace: Born in St. Louis, Missouri.

Education: Bachelor’s degree in Computer Science.

Religion: Non-practicing Christian.

Occupation: IT Consultant, works from home.

Hobbies: Enjoys cycling and hiking in his free time.

Travel: Occasionally travels for work, both domestically and internationally.

Marital Status: Married for 20 years, with two children (ages 17 and 14).

Financial Concerns: None reported, stable income.

Daily Living Habits and Risks: Comprehensive Health Assessment Assignment Paper

– Housing: Homeowner, living in a suburban neighborhood with low crime rates.

– Household Members: Lives with his wife and two children.

– Pets: Has a dog.

– Smoke Detector: Checked regularly.

– CO Detector: Checked regularly.

– Seatbelt Use: Always wears a seatbelt.

– Substance Use: No tobacco or illegal drug use. Occasional alcohol consumption on weekends.

– Diet: Typically follows a Mediterranean diet with plenty of fruits, vegetables, and lean proteins.

– Exercise: Regularly cycles for 30 minutes to an hour each day.

– Sleep Habits: Reports 7-8 hours of uninterrupted sleep each night.

FAMILY HISTORY:

JH reports the following family history: Comprehensive Health Assessment Assignment Paper

– Father (deceased at age 65): Hypertension, heart disease, and type 2 diabetes.

– Mother (alive at age 70): Hypertension.

– One older sister (age 51): No significant medical history.

– Paternal grandfather (deceased at age 78): Hypertension.

– Paternal grandmother (deceased at age 82): No significant medical history.

– Maternal grandfather (deceased at age 75): Hypertension.

– Maternal grandmother (deceased at age 80): No significant medical history.

JH denies any family history of neurological disorders, cancer, autoimmune diseases, or psychiatric conditions.

REVIEW OF SYSTEMS

Constitutional: JH reports no recent weight changes, weakness, or unexplained fatigue. Denies fever or mood changes.

Skin, Hair, and Nails: Skin is intact with no rashes, lesions, or bruising. Hair is evenly distributed with no flaking or hair loss. Nails are pink without clubbing or abnormalities.

Head and Neck: Denies dizziness, lightheadedness, swollen glands, or neck stiffness.

Eyes, Ears, Nose: No changes in vision. Denies eye redness, itching, or discharge. No hearing difficulties or ear pain. No nasal congestion, drainage, or nosebleeds.

Throat and Mouth: No difficulty swallowing, sores, or mouth/throat pain. Reports regular dental check-ups.

Lymphatic: Denies swollen lymph nodes or extremity swelling.

Chest and Lungs: No chest pain, history of asthma, shortness of breath, cough, or bloody sputum.

Breasts: No breast lumps, pain, nipple discharge, or noticeable asymmetry.

Heart and Blood Vessels: Denies palpitations, history of elevated blood pressure, or fainting.

Hematologic: Denies bruising, excessive bleeding, or hematological disorders. No history of blood transfusions.

Gastrointestinal: No constipation, diarrhea, nausea, vomiting, blood in stool, or gastroesophageal reflux. Denies abdominal pain.

Endocrine: Denies heat or cold intolerance, excessive weight changes, hunger, or thirst.

Genitourinary: Reports regular menstrual cycles with no excessive bleeding. Denies genital lesions, itching, or discharge. Denies sexual activity and contraceptive use.

Musculoskeletal:** No muscle weakness, pain, or joint issues reported. Denies back pain.

Neurological: Denies headache (except chief complaint), seizures, memory problems, muscle weakness, speech difficulties, or balance issues.

Mental Health: Denies current or past anxiety, depression, or suicidal thoughts. Not on psychiatric medications Comprehensive Health Assessment Assignment Paper.

OBJECTIVE DATA

Physical Exam:

General Statement: Alert and oriented X3.

– Temp: 98.1°F

– HR: 70 bpm

– RR: 16 breaths/min

– BP: 120/80 mm Hg

– Height: 5’10”

– Weight: 180 lbs

– BMI: 25.8 – overweight

Mental Health: JH appears alert, oriented, and in no acute distress. He engages in conversation with spontaneous speech.

Skin, Hair, Nails: Skin is warm, dry, and intact. No rashes, lesions, or petechiae noted. Hair evenly distributed and without flaking. Nails appear healthy.

Head: Normocephalic and atraumatic.

Eyes: Pupils are equal, round, and reactive to light. Extraocular movements are intact. No papilledema or eye abnormalities observed.

Ears: External ear canals are patent, tympanic membranes are pearly gray, and no cerumen or drainage noted.

Nose: Nares are patent bilaterally with no polyps or discharge.

Throat and Mouth: Oral mucosa is moist without lesions. Tongue is pink and non-enlarged. No dental abnormalities noted.

Neck: Supple neck with no palpable masses or lymphadenopathy. Thyroid gland is non Comprehensive Health Assessment Assignment Paper

-enlarged.

ORDER HERE

Chest: Symmetrical chest wall without deformities, lifts, heaves, or thrills. Normal apical pulsation.

Lungs: Clear breath sounds in all lung fields. No adventitious sounds. No cough.

Breasts: Normal male chest, no palpable masses.

Heart: Regular rate and rhythm, S1 and S2 sounds heard. No murmurs, rubs, or gallops.

Blood Vessels: No varicose veins, palpable carotid pulse, no bruits, no jugular venous distention.

Abdomen: Soft, non-tender abdomen with no palpable masses or organ enlargement.

Genitalia: Normal male genitalia.

Anus and Rectum: Normal anal and rectal exam findings.

Lymphatic System: No lymphadenopathy or extremity swelling.

Neurological: Alert and oriented. Cranial nerves II-XII are intact. Muscle strength is 5/5 in all extremities. Reflexes are 2+ and symmetrical. No coordination abnormalities. Gait is normal.

Laboratory and Diagnostic Studies: No recent laboratory or diagnostic studies.

Assessment Diagnosis: Chronic Migraine Headaches

 

Plan

1. Headache Evaluation:

– Order a complete blood count (CBC) to rule out anemia or other hematological issues.

– Recommend a comprehensive metabolic panel (CMP) to assess electrolyte balance.

– Check thyroid studies to evaluate thyroid function.

– Perform a lipid profile, including total cholesterol, LDL, HDL, and triglycerides.

– Consider obtaining an HbA1C to screen for diabetes.

2. Headache Management:
3. Recommend lifestyle modifications:

– Advise JH to incorporate stress reduction techniques such as deep breathing exercises, progressive muscle relaxation, or mindfulness meditation into his daily routine (Napadow, 2020)Comprehensive Health Assessment Assignment Paper.

– Suggest maintaining regular sleep patterns by aiming for 7-8 hours of sleep per night. Encourage a consistent sleep schedule, avoiding excessive caffeine or screen time close to bedtime.

1. Start a headache diary: Instruct JH to maintain a headache diary to track headache frequency, triggers, and response to treatments (Napadow, 2020). This diary should include:

– Date and time of headache onset.

– Description of headache characteristics (e.g., location, intensity on a scale of 0-10, accompanying symptoms).

– Potential triggers (e.g., specific foods, stressors, lack of sleep).

– Medications taken for headache relief and their effectiveness.

– Any aura or prodromal symptoms if applicable.

– Explain the importance of this diary in identifying patterns and assessing the effectiveness of interventions.

1. Prescribe a triptan medication (e.g., sumatriptan) for acute migraine attacks: Instruct JH on the use of sumatriptan for acute migraine relief:

– Sumatriptan 100 mg tablet (oral) or Sumatriptan 6 mg subcutaneous injection for moderate to severe migraine attacks (Tfelt-Hansen, 2021)Comprehensive Health Assessment Assignment Paper.

– Advise taking the medication as soon as a migraine attack begins, with a maximum dose of two tablets or injections in a 24-hour period.

– Discuss potential side effects, including mild transient symptoms like dizziness, tingling, or flushing.

– Emphasize the importance of not using this medication more than 10 days per month to avoid medication overuse headache.

1. Discuss preventive medications (e.g., topiramate) to reduce migraine frequency if needed: If JH’s headache diary reveals frequent or severe migraines despite acute treatment, consider initiating preventive therapy. Discuss the following preventive medication option: Comprehensive Health Assessment Assignment Paper

– Topiramate (generic for Topamax) starting at a low dose, such as 25 mg orally daily (Smeralda, 2020).

– Gradually titrate the dose up to an effective dose while monitoring for side effects.

– Explain that preventive medications may take several weeks to show their full effect.

– Discuss potential side effects such as dizziness, fatigue, and changes in taste or appetite.

Ensure JH understands the proper use of acute and preventive medications, potential side effects, and the importance of adherence to the treatment plan. Schedule regular follow-up appointments to assess his progress and adjust medications as necessary.

3. Follow-Up:

– Schedule a follow-up appointment in four weeks to assess headache improvement and medication tolerance.

– Provide educational materials on migraine management and headache triggers.

References

Napadow, V. (2020). The mindful migraine: does mindfulness-based stress reduction relieve episodic migraine?. Pain, 161(8), 1685.

Smeralda, C. L., Gigli, G. L., Janes, F., & Valente, M. (2020). May lamotrigine be an alternative to topiramate in the prevention of migraine with aura? Results of a retrospective study. BMJ Neurology Open, 2(2).

Tfelt-Hansen, P. (2021). Naratriptan is as effective as sumatriptan for the treatment of migraine attacks when used properly. a mini-review. Cephalalgia, 41(14), 1499-1505.

Comprehensive Psychiatric Evaluation

 Submit a Comprehensive psychiatric evaluation on an adult and aging adult with a mental illness.

JH, a 48-year-old male, presents to the clinic today with complaints of persistent headaches. Comprehensive Health Assessment Assignment Paper

Comprehensive Psychiatric Evaluation

Source of Information	The patient
CASE PRESENTATION (Presenting features, medical/social/family history of Mental illness.)	Comprehensive Health Assessment for a 48-year old male with Chronic Migraine Headaches.
Demographics should include: age, sex, who they live with, who they are accompanied by for your interview, who referred them to you.	Patient’s Name: JH Date of Birth: 02/15/1975 Race: White Patient Sex: Male Occupation: IT Consultant Insurance: Blue Cross Blue Shield Age: 48 years
Chief Complaint of Patient: Patient’s words	“I am experiencing numerous instances of headaches”
History of Present Illness	JH, a 48-year-old male, presents to the clinic today with complaints of persistent headaches. He describes the headaches as a throbbing pain on the left side of his head, which he rates as 7 out of 10 on the pain scale. He reports that these headaches have been occurring for the past three months, with increasing frequency and intensity. JH states that the pain is usually located behind his left eye and occasionally radiates to his left temple. He further notes that the headaches are often accompanied by photophobia and phonophobia, and he prefers to stay in a dark, quiet room during an episode. The headaches last for several hours and are not relieved by over-the-counter pain medications. He denies any aura, visual disturbances, or other neurological symptoms preceding the headache. Comprehensive Health Assessment Assignment Paper
Current Medications	None but JH mentions that he has been trying to manage his headaches with over-the-counter ibuprofen, but it provides minimal relief.
Past Psychiatric History	None
Past Psychiatric Medications	None
Substance Use/Abuse	No tobacco or illegal drug use. Occasional alcohol consumption on weekends.
Medical History	JH reports a history of childhood asthma, which resolved in adolescence. He has had no recent illnesses requiring hospitalization.
Allergies	No known drug allergies.
Family History	JH reports the following family history: – Father (deceased at age 65): Hypertension, heart disease, and type 2 diabetes. – Mother (alive at age 70): Hypertension. – One older sister (age 51): No significant medical history. – Paternal grandfather (deceased at age 78): Hypertension. – Paternal grandmother (deceased at age 82): No significant medical history. – Maternal grandfather (deceased at age 75): Hypertension. – Maternal grandmother (deceased at age 80): No significant medical history.
Psychiatric and Addiction History	None
Developmental and Social History	None
MSE: Appearance and behavior       Mood   Affect   Thought content   Thought process   Perceptual disturbances   Cognition   Abstract Reasoning   Concentration   Impulsivity   Insight   Judgment   Threat to self or others   Motivation Strength and Weakness     Motor activity   Speech	JH appears alert, oriented, and in no acute distress. He engages in conversation with spontaneous speech.
DIAGNOSTIC TESTS	No recent laboratory or diagnostic studies.
CASE FORMULATION	Headache Evaluation: – Order a complete blood count (CBC) to rule out anemia or other hematological issues. – Recommend a comprehensive metabolic panel (CMP) to assess electrolyte balance. – Check thyroid studies to evaluate thyroid function. – Perform a lipid profile, including total cholesterol, LDL, HDL, and triglycerides. – Consider obtaining an HbA1C to screen for diabetes.
DIFFERENTIAL DIAGNOSIS (with rationale based on DSM 5 and findings	Acute Angle-Closure Glaucoma which leads to optical nerve damage. Such condition leads to severe headaches including eye pain. However, further diagnostics are necessary to ascertain the cause of these symptoms.
DIAGNOSIS: (Include ICD 10 codes)	Chronic Migraine Headaches (ICD-10: G43.709)Comprehensive Health Assessment Assignment Paper.
Treatment Plan:   Pharmacology Psychotherapy Referrals Patient Education	Headache Management: a. Recommend lifestyle modifications: – Advise JH to incorporate stress reduction techniques such as deep breathing exercises, progressive muscle relaxation, or mindfulness meditation into his daily routine (Napadow, 2020). – Suggest maintaining regular sleep patterns by aiming for 7-8 hours of sleep per night. Encourage a consistent sleep schedule, avoiding excessive caffeine or screen time close to bedtime. b. Start a headache diary: Instruct JH to maintain a headache diary to track headache frequency, triggers, and response to treatments (Napadow, 2020). This diary should include: – Date and time of headache onset. – Description of headache characteristics (e.g., location, intensity on a scale of 0-10, accompanying symptoms). – Potential triggers (e.g., specific foods, stressors, lack of sleep). – Medications taken for headache relief and their effectiveness. – Any aura or prodromal symptoms if applicable. – Explain the importance of this diary in identifying patterns and assessing the effectiveness of interventions. c. Prescribe a triptan medication (e.g., sumatriptan) for acute migraine attacks: Instruct JH on the use of sumatriptan for acute migraine relief: – Sumatriptan 100 mg tablet (oral) or Sumatriptan 6 mg subcutaneous injection for moderate to severe migraine attacks (Tfelt-Hansen, 2021). – Advise taking the medication as soon as a migraine attack begins, with a maximum dose of two tablets or injections in a 24-hour period. – Discuss potential side effects, including mild transient symptoms like dizziness, tingling, or flushing. – Emphasize the importance of not using this medication more than 10 days per month to avoid medication overuse headache. ORDER A PLAGIARISM-FREE PAPER HERE d. Discuss preventive medications (e.g., topiramate) to reduce migraine frequency if needed: If JH’s headache diary reveals frequent or severe migraines despite acute treatment, consider initiating preventive therapy. Discuss the following preventive medication option: – Topiramate (generic for Topamax) starting at a low dose, such as 25 mg orally daily (Smeralda, 2020). – Gradually titrate the dose up to an effective dose while monitoring for side effects. – Explain that preventive medications may take several weeks to show their full effect. – Discuss potential side effects such as dizziness, fatigue, and changes in taste or appetite. Ensure JH understands the proper use of acute and preventive medications, potential side effects, and the importance of adherence to the treatment plan. Schedule regular follow-up appointments to assess his progress and adjust medications as necessary.
FOLLOW-UP	Follow-Up: – Schedule a follow-up appointment in four weeks to assess headache improvement and medication tolerance. – Provide educational materials on migraine management and headache triggers.

Hide Assignment Information
Instructions
Background
Obtaining periodic health assessments on patients provides an opportunity for health care providers to get a snapshot on the health status and the health risks of their patients. Health assessment is a process involving systematic collection and analysis of health-related information to identify and support beneficial health behaviors and work to direct potentially harmful health behaviors.

Objectives
a. Develop interviewing skills to obtain a detailed comprehensive history and perform a technically correct physical exam.

b. Identify and prioritize patient health issues, establishing proactive, planned care.

c. Clearly and succinctly document the pertinent data in a logical organized format using appropriate medical terminology.

Instructions
a. Select a client to interview.

b. Obtain a complete history from the client and perform a complete physical exam (no invasive exam)Comprehensive Health Assessment Assignment Paper.

c. Formulate diagnosis and possible treatment plan based on data collected.

d. Document the history and the exam using a standard organized format, including genogram.

e. Include a reference list for any treatment plan that you select in APA format.

Length: 5-7 pages, not including title or reference pages

At least 5 scholarly references; include a reference list for any treatment plan that you select in APA format.

The completed assignment should address all of the assignment requirements, exhibit evidence of concept knowledge, and demonstrate thoughtful consideration of the content presented in the course.

Additional Resources
Click on links below for a sample paper and Grading Rubric for this assignment. Comprehensive Health Assessment Assignment Paper