Your comprehensive health history that was assigned in Module 01 is 10/28/20 due. Complete a comprehensive history, utilizing the form linked below, on either someone over the age of 65 or someone that you know has a lot of medical problems. Write the results in narrative format and include the family history as a genogram (see your text). Visit the following link for help with narrative format: Submit your completed assignment by following the directions linked below. Please check the for specific due dates.
Title: Comprehensive Health History and Genogram Analysis of an Elderly Individual
Introduction:
This paper presents a comprehensive health history and genogram analysis of an individual over the age of 65. The objective of this assessment is to gain insights into the individual’s medical history, lifestyle, and familial health patterns. By utilizing narrative format, this analysis aims to provide a holistic understanding of the person’s overall health status, as well as identify potential risk factors and areas for further assessment.
Background:
The individual chosen for this comprehensive health history and genogram analysis is Mr. Smith, a 70-year-old man who resides in a suburban community. Mr. Smith has a known medical history comprising various health issues. His family medical history will be depicted in a genogram format to understand the potential hereditary factors influencing his health.
Presenting Complaint:
Mr. Smith presents with multiple medical complaints, including chronic obstructive pulmonary disease (COPD), hypertension, osteoarthritis, and a previous history of stroke. He reports experiencing shortness of breath, intermittent chest pain, fatigue, and difficulty in performing activities of daily living. These symptoms have negatively impacted his quality of life and raised concerns regarding his overall health status.
Medical History:
Mr. Smith’s medical history is extensive, indicating a significant burden of chronic and acute conditions. He was diagnosed with COPD ten years ago, following a prolonged smoking habit of over 40 years. His COPD is managed with a combination of bronchodilators, corticosteroids, and pulmonary rehabilitation. Additionally, Mr. Smith was diagnosed with hypertension 15 years ago, for which he takes antihypertensive medications to control his blood pressure. He suffered a mild stroke two years ago, which led to partial paralysis on the right side of his body. Physical therapy and occupational therapy were initiated to aid in his recovery. Furthermore, Mr. Smith has been living with osteoarthritis for the past decade, primarily affecting his knees and hips, resulting in chronic pain and reduced mobility.
Medication History:
Mr. Smith’s medication history includes both prescribed medications and over-the-counter medications. He takes the following medications regularly: albuterol inhaler (bronchodilator) for COPD, lisinopril (angiotensin-converting enzyme inhibitor) for hypertension, aspirin as a thromboembolic prophylaxis following his stroke, and acetaminophen to manage his osteoarthritis pain. He also uses a daily multivitamin supplement. Mr. Smith reports occasional use of over-the-counter antacids for indigestion symptoms and sleep aids for occasional insomnia.
Lifestyle Factors:
In terms of lifestyle, Mr. Smith used to have a sedentary lifestyle before his stroke, with minimal physical activity. However, after his stroke, he started attending physical therapy sessions and adopted a structured exercise regimen to improve his mobility and regain strength. Though he has made progress in his physical abilities, he has difficulty performing strenuous activities due to shortness of breath and joint pain. Mr. Smith used to smoke for over 40 years but has successfully quit smoking for the past ten years. Furthermore, he consumes alcohol occasionally but within moderate limits.
Dietary Patterns:
Mr. Smith follows a balanced diet based on the recommendations of his primary care physician and registered dietitian. He primarily consumes a low-sodium, low-fat diet, rich in fruits, vegetables, whole grains, and lean proteins. He has been advised to limit his sodium intake to manage his blood pressure and reduce fluid retention.
Medical Screening and Prevention:
Mr. Smith receives regular medical screening and preventive services to manage his chronic conditions. He undergoes annual physical examinations, which include blood pressure monitoring, lung function tests, lipid panel, and glucose tests. Additionally, he has regular follow-ups with his pulmonologist, cardiologist, neurologist, and orthopedic specialist to monitor and manage his various health conditions. Mr. Smith also receives annual influenza vaccinations and other recommended immunizations.
In conclusion, Mr. Smith, a 70-year-old individual, presents with an extensive medical history comprising COPD, hypertension, osteoarthritis, and a previous stroke. His medication regimen primarily focuses on managing these conditions. Lifestyle modifications, such as exercise and dietary changes, have been incorporated to improve his overall health status. The genogram analysis will further elucidate the familial health patterns and potential hereditary factors influencing Mr. Smith’s health.