Patient Health History

Health care and Nursing

Patient Health History

Submitted by

Affiliation

Date

Health History components

a) Demographics

a) A 43 years old, unmarried/single African American female with the presenting complaints of pain in her left breast. Lives alone in a comfortable apartment. Material and living conditions are satisfactory, regular meals. In his free time, he walks or rests at home. Complaints about a lump in the left breast are also presented. The patient notes pressing headaches, palpitations.

b) Perception of Health

She is entirely aware of her disease, and she is working hard to lose her weight because her doctor advises her to lose some pounds. He daily uses to talk for 20 minutes and eat healthy food.

Blood pressure 110 / 70-85 mm Hg No protrusion in the region of the heart and large vessels.

Body temperature 36.6. Pulse 80-100 / min, BH 16 / min.

A pulse of sufficient filling and tension, synchronous, rhythmic. A heart rate of 80-100 / min.

c) Past Medical History

According to the patient, in early March, she discovered a tumor in the left mammary gland. The patient consulted an oncologist at the Regional Oncology Center, where she underwent the following examination: mammography, ultrasound examination of the mammary gland, cytology was done. Based on the results of the above-mentioned methods, the oncologist was diagnosed with a left breast blastoma. With this diagnosis, the patient was referred for surgical treatment to the mammalogical department of the Oncology Center. Until the moment of supervision, no treatment was carried out.

Admission to the clinic: March 20, 2019

Diagnosis at admission: Blastoma of the left breast

No past operation/ injuries found.

No allergies

Tuberculosis, hepatitis, venous disease denied.

Blood and blood substitutes were not transfused.

The patient was admitted with complaints of enlarged axillary lymph nodes on the left. Enlarged lymph nodes are not accompanied by pain or other subjective sensations. Complaints about a lump in the left breast are also presented. The patient notes pressing headaches, palpitations. An objective examination revealed a pronounced increase in axillary lymph nodes on the left with a diameter of 2 cm, a dense consistency, smooth, slightly displaced. At the border of the upper quadrants of the left breast, a tumor with a diameter of 1.5 cm without clear contours, tightens the skin of the areola, painless. Other groups of lymph nodes are not enlarged.

d) Family Medical History

Grandmother died at the age of 41 due to a heart attack. Grandfather was healthy and died at the age of 85. Her mother and father separated, so she doesn't have any knowledge about her father. Her mother is alive and having diabetes. She has four healthy siblings with one sister and three brothers. All are healthy, with no physical complaints.

e) Review of Systems

The general condition is satisfactory; I feel good. The expression is meaningful. The behavior is common. The food is normal. Consciousness is clear. The position is active. Height - 160 cm. Weight - 74kg.

The asthenic-type physique is proportional.

There are no pathological changes in the head and face.

There is no visible increase in the occipital, behind the ear, submandibular, chin, posterior and anterior cervical, supraclavicular, subclavian, thoracic, axillary, elbow and popliteal lymph nodes. The anterior cervical, axillary, and inguinal nodes are painless, elastic, mobile, palpation up to 0.5 cm in size. There is a marked increase in the right axillary lymph nodes, noticeable upon examination. On palpation, these nodes are of a dense consistency, painless, welded together, 2 cm in size. The remaining groups of nodes are not palpable.

Palpation is carried out lying on your back with a small roller placed under the shoulder blade of the examined side so that the chest is slightly raised; they feel each mammary gland with the opposite hand in three positions: the hand on the examined side is laid up behind the head, laid aside, lies along the body.

Fingers of the opposite hand feel the outer half of the mammary gland (starting from the nipple and moving outward and upward). Then palpate all areas of the inner half of the mammary gland (starting from the nipple and advancing to the sternum). Determine whether there are nodes, seals, or changes in the structure of breast tissue or the thickness of the skin. Palpate axillary and supraclavicular areas. With moderate finger compression, the areola and nipple check for secretions. A cytological examination of the discharge from the nipples of the mammary gland or punctate of the volumetric masses in the mammary gland is carried out for the early diagnosis of cancer.

f) Developmental Considerations

The patient was born the 1st child, in the family of four children.

Grew and developed according to age.

Obese in her early teens

g) Cultural Considerations

According to NCI, among women ages 40 to 50, African-American women have a higher incidence of breast cancer than white women (Yan, Stevens, Holt, Walker, Ng, & Wang, 2019).

h) Psychosocial Considerations

The patient is single and working as a primary teacher. She loves to spend her time with school children. She is health-conscious, but she doesn't like to cook food at home. She wants to eat meat, vegetables, fruit. Pasta, pizza, and lots of cheese. Her lifestyle is sedimentary. She used to go for a walk 20 minutes daily.

i) Collaborative Resources

Social health is the ability to adapt to the social environment, the full implementation of social functions. Social health reflects social connections, resources, the ability to communicate, and its quality. The level of social health is a measure of social activity and an active attitude of a person to the world around him.

She referred her to join a community weight loss program and some other community program so she can spend her free time in more productive ways instead of boredom associated with loneliness. She is also referred to a nutritionist so she can get knowledge about healthy food.

Reflection

This interview was conducted on Monday, September 30, 2019, at 4.30 pm. This interview was scheduled three days before the meeting. The patient showed her willingness to give this interview. She reached 5 minutes before the scheduled time. She was a well dressed up and physically very active lady. She answered all the questions in detail, and she tried nothing to hide. She was in a perfect mood, and her physical appearance was well-formed. She showed no concern over confidentiality and seemed very positive and optimistic about her future health. She told me that "someday it's not scary to die. It's scary to die right now. Previously, it was believed that cancer was incurable, that it did not need to be treated at all".

Physical health is determined by the body's ability to self-regulate. The perfect coordination of all functions is a consequence of the fact that a living organism is a self-regulating system. Self-regulation is the essence of the natural form of development, i.e., life. This universal property of biological systems allows one to establish and maintain at an individual, relatively constant level-specific physiological, biochemical or other biological indicators (constants), for example, constancy of body temperature, level of blood pressure, blood glucose, etc. order is manifested in the relative dynamic consistency of the internal environment of the body homeostasis.

Through this interview, I learned a lot about interviewing and the kind of questions that I need to ask. I studied about breast cancer and found that breast cancer occurs in 1 woman out of 10. Mortality due to breast cancer is 19-25% of all malignant neoplasms in women. Most often found in the left mammary gland. Most often, the tumor is located in the upper outer quadrant. 1% of all cases of breast cancer are breast cancer in men. The most significant risk factors are female, cases of familial breast cancer. (Yan, Stevens, Holt, Walker, Ng, & Wang, 2019).

The most well-known developmental theories of human life are based on the notion of progressive development — psychoanalyst Erik H. Erikson. Human development is the result of biological maturation, social relationships, and ego activity. At different stages of life, the individual faces development challenges and challenges that are different demands from the environment and changes in the individual. According to Erikson, the developmental problem of each age brings with it a developmental crisis designed to create new abilities and abilities in the individual. Mental work makes an individual struggle through crisis and change and grows into new challenges. An individual's personality basic emotions are shaped, and has at its disposal, as well as positive that the new internal force is containing the negative side.

Self-examination. Unfortunately, self-examination, physical examination, and mammography do not give 100% recognition of a malignant tumor of the mammary gland. The sensitivity of this method is approximately 20-30%. The sensitivity of the technique can be increased through training. However, this method is the cheapest in the diagnosis of breast cancer.

Aspiration needle biopsy. The material is obtained for cytological examination and widely used to establish benign and malignant diseases.

Open biopsy. The most common procedure in the diagnosis of breast cancer. It is performed by local anesthesia.

References

Yan, A. F., Stevens, P., Holt, C., Walker, A., Ng, A., McManus, P., ... & Wang, M. Q. (2019).

Culture, identity, strength and spirituality: A qualitative study to understand experiences of African American women breast cancer survivors and recommendations for intervention development. European journal of cancer care, e13013.