oTriggers/aggravating factorsoSxoEDUCATION/EMPATHY!!!! ESPECIALLY WITH T2DM/BLOOD SUGAR CHECKS, ETC. And “Thank you for telling me about your history…”Social Hx:oEducation level: Tina is in school for her Bachelor’s degree in Accounting.oLiving situation:Tina has recently moved back in with her mother following the death of Tina’s father. oStressors/current stress level:Tina stated “I feel pretty worried about my foot”, this is causing some stress in her life due missing school and work due to oReligious affiliation: Tina is very active in her church. oActivity level:Regular exerciseoOccupation: Tina has works since highschool as a supervisor at Mid-American Copy and ship. She stated she works 32 hours a week and is sometimes flexed
Hrs workedoDiet/nutrition:Last mealWhat?When?Usual daily foodSalt intakeCaffeine intakeRecent diet changesAppetiteSodasoSubstance use:EDUCATION!!!!!!Illicit drugs: DeniesWhat: Smoked potFirst tried when? 15 years oldHow often used? Every weekend but hasent done it in “a long time”Last used? At age 20 or 21AlcoholHow much? She is social drinker of alcohol. She stated no more than two to three in a sitting. First tried when? In high school around age 15 or 16Last drank? At least 3 weeks agoCigarettes/tobacco: DeniesEver?When?How much?Last one?Desire to quit?oHealth maintenance:EDUCATION!!!!ImmunizationsTetanus: Received a tetanus booster about a year ago. Childhood imm: Received a hepatitis vaccination but is unsure it is was hepatitis A or B that she received. Received the meningitis vaccine at 19 years of age. All childhood immunizations she stated she was “pretty sure:” she got. Stated she had the chicken pox andtherefore did not need to get vaccinated. Flu vaxSunscreen/exposure: Tina denies uses sunscreen when outdoors but stated she would use “if I went swimming”.
SeatbeltFire extinguisherHelmetGuns Family Hx:oMom: Still alive and is 50 years old, Hypothyroid, High Cholesterol and hypertensionoDad: Died in a car accident at 58 years old. Has history of Type 2 diabetes, high cholesterol and hypertension. oPGF: Died in his mid 60’s from colon cancer. Has history of Type 2 diabetes and high blood pressure.oPGM: Still alive history of hypertension.oMGF: Died of a heart attack. Hypertension and cholesterol.oMGM: Died at age 73 from a stroke. High cholesterol and hypertension.oSiblings: Brother who is overweight and Younger sister who has asthma. oUncle with a history of Alcoholism.oEDUCATION/EMPATHY!!!!! “I’m so sorry your dad died…. Thank you for telling meabout your family history…”ROS:oConstitutional:General well-being: Recent illnessSleep patterns: Recent change in sleeping patterns after the death of her father. Tina stated that she tries to get 8 hour but has only be achieving between 6 or 7 hours a night.
You've reached the end of your free preview.
Want to read all 17 pages?
- Fall '15