Health History

Health History

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Institution

Health History

Patient Demographics

The patient is a female, and her name is P. He age is 37, and by ethnicity, she is an Asian immigrant in living in the United Stated currently. She belongs to a lower middle class and hardly meets her basic needs.

Chief Complaint

She is diagnosed with oral squamous cell carcinoma. She had an injury on her chin while playing football six months ago. She went for proper treatment, and she had to undergo several stitches. Now, her injury has become into a tumor, and according to her, the size of the tumor continued expanding right after the surgery. She says that she has excessive pain in her whole head and she can barely talk or eat anything.

Past Medical History

There is no past medical history. The only treatment she underwent was during her injury. She has also received basic immunizations in her adolescents and maternity.

Current Health Status

Her current health status is deteriorating as she suffers from severe headache and low blood pressure level. She often suffers from low blood glucose level. She has pain in her neck, back and legs. She is also suffering from anorexia and feels nauseous all the time.

Genogram

She has two children, a daughter and a son. She has three siblings, two brothers and one sister. Her mother has died while her father still lives. Her grandparents are dead for quite many years.

Family History

Her children are quite healthy except for her daughter, who often falls ill after a couple of months. Her brother is suffering from high blood pressure while sisters are leading a normal healthy life. Her mother died seven years ago due to cardiac arrest while her father is alive and suffers from lung cancer. Her grandmother died of tuberculosis while her grandfather died of cardiac arrest.

Personal and Social History

P is a simple housewife and mother of three kids. Her husband works for a multi-national company. She has a limited social circle with few friends. Visiting the places of her friends, inviting them to her place, going for lunch or shopping with them are some of the recreational activities that she is involved into. She is a smoking addict.

Review of Systems

The assessment of different health parameters is taken into subjective and objective consideration. It includes the following parameters;

Gastrointestinal (nausea, vomiting, heartburn, abdominal pain, diarrhea, bloating)

Cardiovascular health (chest pain, palpitations, abnormal heart rhythm)

Respiratory condition (cough, wheezing, shortness of breath)

Genitourinary situation (frequent urination, kidney failure)

Endocrinology (menstrual cycle, metabolic syndrome)

Musculoskeletal (immobility, osteoporosis, lower back pain)

Integumentation (skin tags, stretch marks, cellulitis)

Neurologic (dementia, stroke)

Psychological examination (depression, social stigmatization)

Nutritional Assessment

Her diet intake is very poor. She hardly consumes healthy food. Most of her diet intake consists of junk food that is responsible for her failing health and low calorie count. Her BMI is also below the average score.

Risk Factors

Her smoking and poor eating habits are responsible for her poor respiratory health. There are chances of cardiovascular diseases that she may suffer from. There might be an association of her oral squamous cell carcinoma with her smoking habits, and the injury was just the triggering factor in activating the proto-onco genes in her DNA.

Health Promotion

Patients suffering from oral cancer usually hail from lower socio-economic backgrounds. Thus, it is essential that they are not exposed to avoidable risk factors, which include environmental carcinogens, infectious agents, alcohol, and tobacco. Furthermore, psychological morbidity is rather common among adults suffering from oral cancer. Thus essential care should be provided to such patients. Oral squamous cell carcinoma may also impact intimate relationships among partners, which is another area where nurses can help out to alleviate the distress the patient is going through and refer them to the appropriate professionals.