|Date of birth:||16.06.1982|
|Marital status:||Married (no children)|
|Source of information:||Randomly selected acquaintance|
|Reliability of source of information:||The source is reliable.|
Present Health History/Illness
Reason for seeking care
Migraine, body stiffness, giddiness, fainting, fits of feebleness and irritation, ragweed allergy.
The patient has standard Medicare health insurance. Receives consultations from the physician. Underwent several courses of migraine treatment. Frequent tension headaches seem to block everyday activity.
Searching of effective treatment for her migraine.
Health Beliefs and Practices
Beliefs and practices
Deep sleep is regarded by the patient as the best method to treat headaches, although she has problems with falling asleep. It is also believed that walking might be helpful to feel better.
Factors influencing healthcare decisions
Healthcare decisions might be influenced by health condition which varies depending on the situation. The methods of alternative medicine are ignored. New medications and treatment methods are paid attention to.
Related traits, habits or acts
The patient does not take alcohol, tobacco, and coffee. She takes a lot of tea.
During the last visit to a hospital, the patient was prescribed topiramate and propranolol as oral medications, as well as injections of vitamin complex.
Ibuprofen and aspirin are also used to fight headaches. Xyzal is used in the seasons of acute allergy.
Herbals are not considered as an effective treatment by the patient.
Broken hand and overweight. The broken hand was treated successfully. The overweight is still a problem. It is noted that body composition changes caused by dietary should be taken into account in the process of disease management and decision-making (Toomey, C. M., Cremona, A., Hughes, K., Norton, C., & Jakeman, 2015).
All necessary vaccinations were received in the childhood.
The patient is allergic to ragweed.
The patient had one hospitalization in her childhood caused by the broken hand.
Labor and deliveries
Use of alcohol
Not addicted to alcohol.
Use of tobacco
Does not use tobacco.
Use of illicit drugs
Never used drugs.
Mental, emotional or psychiatric problems
The patient feels depressed sometimes because of her headaches. Is liable to emotional outbreaks and rage.
The patient’s father is still alive. He is retired. Suffers from cardiac disease.
The patient’s mother is alive as well. She is also retired. Has no particular illnesses, except overweight.
The patient has one brother. He has no chronic diseases.
Both grandparents are dead. The patient states that one of her grandmothers suffered from diabetes. The state of health of other parents is unknown.
The patient never had any job and is occupied as a housewife.
The patient graduated from the university in 2005. She has master’s degree in economy.
The patient grew up in the family with middle income. Her husband has his own auto repair shop.
Roles and Relationships
The husband plays a significant role in her life.
The patient is supported by her husband, parents, and brother. They advise her to continue migraine treatment.
Ethnicity and Culture
Ethnicity and culture
The patient is Caucasian. Her parents are believed to have a German origin.
Physical and social characteristics that influence healthcare decisions
The patient looks healthy. Shows signs of paleness due to her constant migraines.
Religious and spiritual needs
The patient is a loyal Catholic.
View of self-worth
The patient has low self-esteem.
She is planning to have at least two children by the age of forty.
Review of Systems
Skin, hair, nails
The skin is healthy. The hair is dull and partly grey. Her nails do not have any signs of deformity.
Head, neck, related lymphatics
The lymph nodes of the patient are healthy. Her neck and head appear to function well.
The patient has shortsightedness and utilizes glasses.
Ears, nose, mouth, and throat
The patient has to visit a dentist more than twice a year. Her nose, mouth, and throat appear to be healthy.
The breathing functions are normal.
Breasts and axillae
The patient’s breasts and axillae are healthy.
The heartbeat of the patient is within the norm.
The blood circulates properly.
The patient has some excessive weight.
Urination functions are normal.
The patient is in reproductive age and has no specific complaints.
No specific problems.
No problems detected.
Toomey, C. M., Cremona, A., Hughes, K., Norton, C., & Jakeman, P. (2015). A review of body composition measurement in the assessment of health. Topics in Clinical Nutrition, 30(1), 16-32.