a. Vital signs: height-165 cm, weight-95 kg.  Blood pressure 154/85, pulse 61, respiratory rate 16, oxygen saturation 98% on room air, temporal temperature 97.6 F. She does not use dentures or hearing aids.  She has no known drug allergies.  Mary uses reading glasses to see things up close.  She does not use contact lenses, dentures, hearing aids or any assistive devices for mobility.   She states that she eats three meals a day.  This morning for breakfast she ate two scrambled eggs with white toast and drank one cup of coffee with sweet and low and creamer.  For lunch she had a tuna salad sandwich and some chips, and for dinner she plans on stopping on her way home to pick up hoagies for her and her husband to eat for dinner.  She plans on getting an Italian sandwich with French fries.  She always carries snacks with her because she is a type 2 diabetic and can feel it when her sugar runs low.  She usually has some trail mix for a snack and/or some fruit.  She also eats candy at work when people bring in candy to share or donuts in the morning from other staff members.

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2. Source of referral

a. Vonnie was not referred to take part in this assessment, she was sought out as a participant by a student the she works with. Vonnie consented to the assessment as a way to help a co-worker.

2.  Health History
   1. The reason the client is participating in this assessment is for educational purposes.
   2. Past Health History
      1. Childhood illnesses- Client reports history of chicken pox, unsure of date.
      2. Adult illnesses- Client reports gastroesophageal reflux disease, type 2    diabetes mellitus, and hypertension.  She was diagnosed with colon cancer in 1995.  She went through radiation and chemotherapy treatments and is now cancer free.

3.   Psychiatric illnesses- Client does not have any diagnosed psychiatric illnesses.

4.   Injuries- Client reports no history of injuries.

5. Operations- Client reports surgeries but is not sure of the dates.  Low anterior resection and hysterectomy (both at the same time), implanted port, port removal, open cholecystectomy, and tubal ligation.
   1. Current Health Status
      1. Allergies- Client has no known drug allergies.
      2. Immunizations- Client is up to date on all of her immunizations.  She receives the flu vaccine every year, her last flu vaccine was in September 2018.
      3. Screening tools- Client attends a yearly physical exam at her primary care Physician (PCP) where she is tested and screened for depression and alcohol misuse.  Her blood pressure is measured and recorded to help control her high blood pressure.  Her A1C is checked to help monitor her diabetes.  Weight is measured at her yearly physical, although she is supposed to keep track of it and work on losing weight throughout the year which she does not participate.  Weight loss and diet are discussed at her yearly physical.  She is screened for lipid disorders every 5 years as part of her physical as well.  Client is screened more closely than the recommended 5 years for colorectal cancer because she has a history of colon cancer.  She is screened with a colonoscopy every 3 years and has bloodwork done every year.  Client has a yearly mammogram and a pap smear to screen for cervical cancer every 3 years.
      4. Environmental hazards- An environmental hazard is something that has the potential to cause an individual harm that is a material, a substance or a state of the surrounding environment that can harm people (White, Hall, & Johnson, 2014).
      5. Vonnie does not have a regular exercise routine.  She states that she mostly sits each day at work or home.  On her days off she cooks and cleans and goes shopping.  She enjoys watching television and goes bowling once a week.
      6. Vonnie reports a regular sleep schedule.  She works three days a week so she gets up at the same time on those days and also on her days off.  She reports between 8-9 hours of sleep per night.  She reports that she does not always feel well rested even with the recommended amount of sleep.
      7. Vonnie eats 2-3 meals per day.  She reports that sometimes she does not have time to eat 3 meals especially when she is at work, but she snacks throughout the day.  Vonnie always has something to eat on her in case her blood sugar drops, usually a piece of hard candy or a glucose packet.  She says that a typical day includes a breakfast bar for breakfast, a tuna melt with a side of fruit for lunch, and something quick for dinner that she picks up on her way home from work such as an Italian hoagie and French fries.  According to the Mini Nutritional Assessment (MNA) by Vellas, Garry, & Guigoz, (1999), Vonnie is normal nutritional status.
      8. Vonnie’s medications include: Tresiba subcutaneous once a day (dose dependent on blood sugar reading), Trulicity 1mg by mouth once a week, Jardiance 10mg by mouth every morning, Welchol 1.875mg by mouth twice a day with meals, Lipitor 40mg by mouth once a day in the evening, and Micardis 40mg by mouth once a day in the morning.
      9. Vonnie reports that she does not smoke anymore.  She has a history of smoking cigarettes, 1 pack a day for 20 years.  She quit in smoking in 1998.  She denies any smokeless tobacco use.
      10. Vonnie reports that she drinks alcohol socially on rare occasions.  She drinks either a fruity mixed drink or a wine spritzer.  Mary denies use of any illicit drugs.
      11. Vonnie describes her typical day as she gets up for work around 6am.  She eats a small, quick breakfast and then drives 15 minutes to work.  She works as a secretary from 8:00am-8:30pm at a community hospital.  She takes a 45 minute lunch break and a 15 min break during the day to eat and to get off of the unit.  When she gets home she eats a small meal and watches television.  On her days off Vonnie goes shopping at Target and the grocery store, she cooks and cleans, and sometimes spends time with her daughter and her grandchild.  She sometimes helps her daughter with her grandson by picking him up from daycare or watching him while her daughter works.
      12. Computer vision syndrome is a term used to describe issues that one might complain of after sitting in front of a computer for long periods of time such as neck/shoulder pain, eye strain, and visual problems (Gowrisankaran & Sheedy, 2015).

2. Family History

   1. Mary’s father died of a heart attack when she was a young child.  Her mother died of renal disease, her mother had a history of high blood pressure and diabetes.  Mary is an only child.  Mary’s children have no signifancant past medical history problems.  A Geneogram has been included to show her history.  Mary states that she thinks her blood pressure issues are genetic and she received the genes from both her mother and father..

KEY:

E. Review of Systems and Health Promotion Activities

1. General Survey: Vonnie lives in a suburb of Pittsburgh, PA in a house with her husband, her 38-year-old son, and her dog.  Mary appears the age that she reports.  She is sitting in a chair in no distress.  She is calm and cooperative.
2. Skin, Hair, and Nails:  Vonnie’s skin in pink and warm.  Hair well kept.  No clubbing of nails.
3. Head, Face, Neck & Lymphatics:  No complaints of dizziness or drowsiness.  No pain reported in neck.  Smile symmetrical.
4. Eyes and Vision: Vonnie report that her vision is 20/20.  No complaints of floaters or dark spots.  No complaints of dry eyes or blurred vision.  Mary has an eye exam annually.
5. Ears and Hearing:  No complaints of ringing in ears or ear pain.
6. Nose and Sinuses:  No complaints of congestion, no drainage noted.  Occasional seasonal allergies reported, Mary says she does not take anything to ease mild symptoms of itchy eyes and runny nose.
7. Mouth and Throat:  Mouth moist, lips pink.  Teeth are her own, no dentures.  No bumps or lumps on neck.  Mary has an annual dental cleaning and dental exam.
8. Chest, Thorax, and Lungs: No complaints of shortness of breath, no chest pain.  Mary reports that she can walk up a flight of stairs with no chest pain or shortness of breath.
9. Breasts: No complaints of tenderness or pain.  No noted problems with breasts.  Mary receives a mammogram annually.  She does not do self-examinations monthly.
10. Cardiovascular System:  Vonnie has a history of high blood pressure.  She checks her blood pressure monthly.  She takes medication to control blood pressure.  She sees her PCP quarterly to help monitor her blood pressure.
11. Peripheral Vascular:  No complaints of ankle swelling or varicose veins.
12. Gastrointestinal:  Vonnie complains of upset stomach, she reports that sometimes when her blood sugar level is low that she gets an upset stomach.  No complaints of nausea.
13. Urinary:  No complaints of frequency or urgency.  No reports of burning with urination.
14. Genital, Reproductive:  Vonnie is post-menopausal.  No complaints of drainage from vagina.  Mary attends an OB/GYN check-up annually.
15. Musculoskeletal:  No assistive devices used to ambulate.  No complaints of pain in joints or muscles.
16. Neurological:  No complaints of dizziness.  Speech clear and appropriate.  No history of strokes or seizures.

F. Screening Tool

1.  Vonnie reports feeling of stress on a daily basis, therefore, the Family Inventory of Life Events and Changes (FILE) tool was used to screen for stress.  The participant is to fill out the form marking YES or NO next to the box next to the listed event/change.  The instructions state that this event/change must have happened within the last twelve months.  There is a number next in the corresponding box.  The numbers next to the boxes checked YES are calculated together for a total number.  According to the tool, totals of 750 points and up are considered high scores, and totals of 501-749 are moderate scores and the participant should be informed of their significant stress score and assisted in establishing positive coping strategies (McCubbin, Patterson, & Wilson, 1991).  Figure 1 shows the FILE assessment tool.