hello, attached is the past paper (part 1) and the current assignment.

1. Biographical Data

Name: Bethany Osamade Ogbeifun Phone: 832-706-9538

Address: 4592 Chapel Street, Houston Texas 77002

Birthdate:10-17-1996 Birthplace: Chino, California Age:25 Gender: Female Marital Status: Single Occupation: Human resources coordinator

Race/Ethnic Origin: Black non-hispanic Employer: NES Fircroft

2. Source and Reliability

Patient’s statements.

3. Reason for Seeking Care

4. Present Health or History of Present Illness

5. Past Health

Describe general health: My health is okay currently, but I hope that it gets better. Childhood illnesses: Sickle cell

Accidents or injuries: None

Serious or chronic illnesses: Sickle cell (5 months)

Hospitalizations: Memorial Herman- katy, sickle cell crisis

Operations: Appendectomy 20yrs

Obstetric history: Gravida:0 Term:0 Preterm: 0 Ab/incompletes:0 Children living: 0

Course of pregnancy: N/A

Immunizations: Covid, measles, mumps, rubella, meningitis

Last examination date: Physical-02-22 Dental-08-20 Vision- 02-18

Allergies: _Pollen, dust Reaction, Stuffy nose, sore throat, red eyes

Current Medications: Folic Acid, Pregabalin

6. Family History – Specify Which Relative(s)

Heart disease: None Allergies: None High blood pressure Mother, aunt, uncle Asthma: Brother, sister Stroke: None Obesity: None Diabetes: None Alcohol/drug addition: Aunt, and uncle, brother

Blood disorders: Sister, cousins, aunt Mental illness: None Breast/ovarian cancer: None Suicide: None Cancer (other): None Seizure disorder None Sickle cell: Sister, cousins, aunt kidney disease: Aunt (father's side)

Arthritis: None Tuberculosis: Half-brother, uncle Construct genogram below

Describe circled items

General Overall Health State: present wt (gain or loss, period of time, by diet or other factors), fatigue, weakness or malaise, fever, chills, sweats or night sweats.

Patient noted no loss of weight, no fever, weakness, fever, chills, or sweats

Skin: history of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion.

Patient reports having Eczema (diagnosed at 5yrs), patient reports having acne. Excessive dryness, and Rashes on her skin due to eczema.

Hair: recent loss, change in texture.

Patient noted no hair loss or change in texture

Nails: change in shape, color, or brittleness.

Health Promotion: Amount of sun exposure, method of self-care for skin and hair.

No brittleness, change in shape or color noted in the patients’ nails

Health Promotion: Increase amount and frequency of sun exposure and take more time for care of hair (self-care) and increase water intake.

Head: any unusually frequent or severe headache, any head injury, dizziness (syncope), or vertigo.

Patient reports occasional dizziness, Reported no previous head injuries, or vertigo.

Eyes: difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts.

Health Promotion: wears glasses or contacts, last vision check, or glaucoma test, how coping with loss of vision, if any.

Reports short sightedness stigmatism in left eye.

Reports no glaucoma or cataract. NO eye pain, redness or swelling noted on assessment.

Health Promotion: Patient does not wear glasses recommended that she does. Get vision checked regularly, and glaucoma test.

Ears: earaches, infections, discharge and its characteristics, tinnitus, or vertigo.

Health Promotion: hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, method of cleaning ears.

Patient reports no earaches, frequent infections or characteristics or tinnitus or vertigo.

Health Promotion: Be cautious of exposure to loud noises, practice safe ear cleaning techniques (do not use Q-tips)

Nose and Sinuses: discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell.

Occasionally bloody nasal discharge, Blood is dry. Occasional nose bleeds due to weather change. Patient reports no severe colds. Patient reports seasonal allergies, no change in sense of smell.

Mouth and Throat: mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste.

Health Promotion: pattern of daily dental care, use of prostheses (dentures, bridge), last dental checkup.

Toothache, occasionally patients report toothache as a result of tooth being pulled.

Health Promotion: Promote proper care of artificial teeth. Get regular dental checkups last checkup was 6 years ago.

Neck: pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter.

Patient reports no neck pain or limitation of motion. No swelling or enlarged or tender nodes noted upon assessment. No goiter noted.

Breast: pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts.

No pain noted in the breast. No nipple discharge, no rash on chest reported. No history of breast disease or surgery on breasts.

Axilla: tenderness, lump, or swelling, rash.

Health Promotion: performs breast self-exam, including frequency and method used, last mammogram and results.

No tenderness, swelling, lumps, or rashes noted on the axilla bilaterally.

Health promotion: Recommend patient to perform self-examination of breast, Patient has reported never having a mammogram or breast examination done by a medical professional.

Respiratory System: history of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure.

Health Promotion: last chest x-ray exam.

Patient has no history of lung disease. Notes no chest pain when breathing, no wheezing or noisy breathing. Long periods of strenuous activity produce shortness of breath. (Workouts, running,) No toxin or pollution exposure.

Health Promotion: Get regular chest x-ray exams, work on building stamina to increase the amount of strenuous activity that you can do (exercise regularly)

Cardiovascular System: precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hyptersion, coronary artery disease, anemia.

Health Promotion: date of last ECG or other heart tests and results.

Patient experience chest pain rarely. Patient has history of hypertension, her mother, aunt and uncle all have hypertension, edema, or other heart related diseases.

Health Promotion: Encourage patient to follow up and get checked regularly for her blood pressure. Encourage patients to schedule chest examinations, and ECGs and to get checked out if she experiences any abnormal chest pains.

Peripheral Vascular System: coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers.

Health Promotion: if work involves long-term sitting or standing, avoid crossing legs at the knees, wear support hose.

Patient reports no feelings of coldness, numbness, or tingling in the legs. No swelling of the legs noted. No discoloration, noted in the hands or feet. No varicose veins or claudication, thrombophlebitis, or ulcers.

Health Promotion: Encourage patients to move legs regularly when sitting for a prolonged period of time (sitting at work) suggest the use of support hose and avoiding crossing legs when sitting.

Gastrointestinal System: appetite, food intolerance, dysphagia, heartburn, indigestion pain (associated with eating) other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and

Patient reports that appetite is Not great. Patient eats 1-2 times a day, has occasional indigestion because of irregular eating schedule, Patient has Stomach ulcers, and has had appendicitis, (appendix was removed). Patient notes no history of irregular bowel movements, or changes in stool. No black stool, constipation, or diarrhea reported.

vomiting (character), vomiting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel movements, any recent change, stool characteristics, constipation, or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula).

Health Promotion: use of antacids or laxatives.

Health Promotion: If the patient experiences constipation, use laxatives. Recommend that patient consumes balanced diet with fiber to ensure regular bowel movements.

Urinary System: frequency, urgency, nocturia (number of times awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region or low back.

Health Promotion: measures to avoid or treat urinary tract infection, use of Kegel exercises)

Patient notes Urine Yellowish on occasion only occurs When patient repots dehydration. Patient reported no cloudiness, or hesitancy when urinating. No pain during urination, or discoloration of urine.

Health Promotion: Encourage patient to practice hygienic bathroom habits, to prevent urinary tract infection. Encourage patient to stay hydrated to promote regular urination.

Male Genital System: penis or testicular pain, sores or lesions, penile discharge, lumps, hernia.

Health Promotion: Performs self-testicular exam? How frequently?

N/A

Female Genital System: menstrual history (age of menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding.

Health Promotion: last gynecologic checkup, last Pap test and results.

Patients’ menarche age 9. last menstrual cycle as of the time of interview was 12th of March duration 5 days. No premenstrual pain or spotting reported. Patient reports no vaginal itching, or irregular discharge. Discharge colored clear and sticky in texture. No signs of menopause.

Health Promotion: Encourage patient to get gynecological checkup. Patient did not remember last pap smear or the results.

Sexual Health: Presently in a relationship involving intercourse? Are aspects of intercourse enjoyable for you and your partner? Any dyspareunia (for female), any changes in erection or ejaculation (for male), use of contraceptive, is contraceptive method satisfactory? Use of condoms, how frequently? Aware of any contact with partner who has sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis)?

Patient reported not currently being involved in a relationship involving intercourse. Patient reports not experiencing dyspareunia, patient does not use oral contraceptives, uses condoms “it works well enough”. Patient is not aware of any contact with a partner that has sexually transmitted infections. Patient has no sexually transmitted infections.

Musculoskeletal System: history of arthritis or gout. In the joints, pain, stiffness, swelling? (Location, migratory nature), deformity, limitation of motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait problems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease.

Health Promotion: how much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Any mobility aids used?

Patient reports Pain and stiffness in all her joints. Noted noise with joint movement, cramps and weakness in muscles, Back pain all over the back. No deformity observed or gait problems, patient is coordinated, and has no history of disk disease. Patient uses no mobility aids

Health Promotion: Patient barely walks per day, Encourage increased movement for patient.

Neurologic System: history of seizure disorder, stroke, fainting, blackouts. In motor function: weakness, tic or tremor, paralysis, coordination problems. In sensory function: numbness and tingling (paresthesia). In cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations.

Patient has no history of seizure disorders, stroke, or fainting. Patient reports no tics, tremors, paralysis, or coordination problems. NO numbness, or tingling noted. Patient has no history of memory disorder, mood change, depression, mental health dysfunction, or hallucinations.

Hematologic System: bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.

Patient has sickle cell disease. But has no tendency of bleeding through the skin or mucous membranes. Patient notes no excessive bruising, lymph node swelling, exposure to toxic agents or radiation, or blood transfusion reactions.

Endocrine System: history of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat or cold, changes in skin pigmentation or texture, excessive sweating, relationship between appetite and wt, abnormal hair distribution, nervousness, tremors, need for hormone therapy.

Patient has no history of diabetes, thyroid disease, intolerance to heat or cold, changes in skin pigmentation or texture. Patient reports no excessive sweating and a good relationship between her appetite and her weight. Patient notes no abnormal hair distribution, nervousness, or tremors.

Functional Assessment (including Activities of Daily Living

Self-Esteem/Self-Concept: Education (last grade completed, other significant training): Masters,

Financial status: Patient notes that Income is inadequate to support both health concerns and lifestyle.

Value-belief system: Patient practices Christianity, and believes that a personal strength or accomplishment is getting her degrees despite her health challenges

Self-care behaviors: taking Bath, patient notes that she is unable to do much because of her financial situation. Patient enjoys spending time with people, she feels safe around.

Activity and Exercise: daily profile, usual pattern of a typical day: Minimal physical activity, sits at desk and uses computer

Leisure activities: Swimming, Movies, ping-pong, out to eat (ordering food in)

Exercise pattern: Patient does not exercise often. Her main physical activity is walking short distances. (To the mail)

Sleep and Rest: sleep patterns, daytime naps and any sleep aids used: Irregular, cannot stay asleep or can’t get to sleep. Prescribed zolpidem but does not take it regularly, notes naps in the daytime

Other self-care behaviors:

Nutrition and Elimination:

Who buys food? Patient does Who prepares food? Patient does

Finances adequate for food? Patient notes that finances are adequate for food

Who is present at mealtime: Patient eats alone

Other self-care behaviors: patient states that she has none