Patient with Migraine: Health History and Assessment

Biographical Data

Date: 28.01.2018
Initials: O.R.
Age: 35
Date of birth: 16.06.1982
Birthplace: Miami, FL
Gender: Female
Marital status: Married (no children)
Race: Caucasian
Religion: Catholic, Christian
Occupation: Housewife
Health insurance: Medicare
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.

Health patterns

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.

Health goals

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.

Medications

Prescription medications

During the last visit to a hospital, the patient was prescribed topiramate and propranolol as oral medications, as well as injections of vitamin complex.

Over-the-counter medications

Ibuprofen and aspirin are also used to fight headaches. Xyzal is used in the seasons of acute allergy.

Herbals

Herbals are not considered as an effective treatment by the patient.

Past History

Childhood diseases

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).

Immunizations

All necessary vaccinations were received in the childhood.

Allergies

The patient is allergic to ragweed.

Blood transfusions

None

Major illnesses

None

Injuries

Broken hand

Hospitalizations

The patient had one hospitalization in her childhood caused by the broken hand.

Labor and deliveries

Not utilized.

Surgeries

None.

Use of alcohol

Not addicted to alcohol.

Use of tobacco

Does not use tobacco.

Use of illicit drugs

Never used drugs.

Emotional History

Mental, emotional or psychiatric problems

The patient feels depressed sometimes because of her headaches. Is liable to emotional outbreaks and rage.

Family History

Father

The patient’s father is still alive. He is retired. Suffers from cardiac disease.

Mother

The patient’s mother is alive as well. She is also retired. Has no particular illnesses, except overweight.

Siblings

The patient has one brother. He has no chronic diseases.

Grandparents

Both grandparents are dead. The patient states that one of her grandmothers suffered from diabetes. The state of health of other parents is unknown.

Psychosocial/Occupational History

Occupational history

The patient never had any job and is occupied as a housewife.

Educational level

The patient graduated from the university in 2005. She has master’s degree in economy.

Financial background

The patient grew up in the family with middle income. Her husband has his own auto repair shop.

Roles and Relationships

Significant others

The husband plays a significant role in her life.

Support systems

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.

Spirituality

Religious and spiritual needs

The patient is a loyal Catholic.

Self-Concept

View of self-worth

The patient has low self-esteem.

Future plans

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.

Eyes

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.

Respiratory

The breathing functions are normal.

Breasts and axillae

The patient’s breasts and axillae are healthy.

Cardiovascular

The heartbeat of the patient is within the norm.

Peripheral vascular

The blood circulates properly.

Abdomen

The patient has some excessive weight.

Urinary

Urination functions are normal.

Reproductive

The patient is in reproductive age and has no specific complaints.

Musculoskeletal

No specific problems.

Neurologic

No problems detected.

Reference

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.

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