Patient AM, a 35-year-old nurse, presented to the hospital complaining of persistent diarrhea and abdominal cramps for two days. She reports having 5 episodes of watery diarrhea per day since returning from a family picnic. Over-the-counter Imodium provided no relief. Her past medical history is otherwise unremarkable. A review of systems is negative except for the presenting complaints. She has no significant family history. A physical exam will be performed to further evaluate the cause of her diarrhea and abdominal cramps.

1. 1
Health History
2
Health History
Health History
Name
Global Health College
Health Assessment
10/16/2015
Date __10/5/2015___
Examiner M. A.
1. Biographical Data
Initials __AM__ Phone __3017934596____
Address ___7001 96 Avenue, Lanham MD 20706
Birth date 07/28/1980 Birthplace Limbe, Cameroon___
Age __35__ Gender __Female__ Marital Status _Married__
Occupation _Nurse__
Race/ethnic origin __Black/Cameroon__ Employer __Karen

2. For Kids Inc.__
2. Source and Reliability: The source of information is reliable
because it is provided by the patient herself.
3. Reason for Seeking Care: Patient is seeking help because she
has been having persistent diarrhea and abdominal cramps for
two days.
4. Present Health or Health of Present Illness: Diarrhea and
abdominal cramps.
Patient AM, came to the hospital at 4pm on 10/5/2015,
complaining of persistent diarrhea and generalized abdominal
cramps. She states that her illness started after she came back
from a family swimming picnic on 10/2/2015 at 7pm. She states
that her illness started with generalized abdominal cramping
that was followed with her passing watery non-tarry stool with
no foul smell. She says she has been having 5 episodes of
diarrhea each day for two days. Patient also states that her
illness is triggered when she eats any food or when she wants to
do her daily exercise. Patient states she feels a little weak.
Patient added that she has also taken Over The Counter (OTC)
Imodium 4mg twice a day for two days but doesn’t feel any
better. That is why she came to the hospital today for help.
5. Past Health
Ms AM says she has been healthy over the past years,
except for today when she complains of diarrhea and abdominal
cramps. She denies having any past history of childhood
illnesses: measles, chicken pox, mumps, meningitis, impetigo.
Patient confirms haven had pink eye at age 10years old, which
was treated with some home remedies (soaked clean compress
and OTC eye drop called artificial tears). Patient says she had a
minor nose injury at age 12 years that was treated by her
pediatrician with pain medication. Patient denies having history
of any chronic illness: diabetes, hypertension, asthma, cancer,

3. Congestive Heart Failure (CHF), Coronary Artery Disease
(CAD), or stroke.
Patient denies haven been hospitalized before except
during delivery. She also denies having any surgical procedures.
Patient states that she has been pregnant three times, and she
has three babies, two boys and one girl. She went ahead to say
she had no premature procedures, delivery, abortion, or
miscarriage. She added that all of her babies were carried full
term and delivered after 9 months. of pregnancy. She labored
for 4 hours for her first baby who was a boy, and 3 hours each
for both second and third babies, a boy and a girl consecutively.
She said her first baby weighed 7lbs and the other two weighed
8lbs each. All her three babies were delivered vaginally with no
complications.
Patient states she is up to date with all her immunization,
such as; influenza, pneumococcal, hepatitis “A and B”,
varicella, and DT aP vaccines. She also states that her last
examination was when she went for her yearly physical exam on
August 15th 2015 where she did her complete blood work, EKG,
chest x-ray, pap smear, and all her results were normal.
She denies having any drug or food allergy, and her body has
never reacted to any food, medication, or herbs. She has been
taking 4mg Imodium twice a day for the past two days for her
diarrhea.
6. Family History – Specify
When interviewed, patient denies having any family
history of: heart disease, high blood pressure, stroke, diabetes,
blood disorders. She also denies having a family history of
sickle cell, arthritis, obesity, asthma. She denies family history
of any allergies: drugs, food, herbs. She continues that her
family has no history of suicide, kidney disease, tuberculosis, or
seizures. However, patient confirms that her family has a
history of breast cancer. She says her mother was diagnosed
with breast cancer six years ago and was treated with a series of

4. chemotherapy. She added that her mother is a breast cancer
survivor today.
Genogram
(
Mother: 62 years old
History of breast cancer.
Diagnosed with breast cancer six years ago.
) (
Father: 65 years old
No history of illness or chronic disease.
)
(
Sister
: 33 years old
No history of illness
or chronic disease.
) (
Patient: 35 years old
Presently complains of d
iarrhea and abdominal cramps
.
) (
Brother
: 38 years old
No history of
illness

5. or
chronic disease.
) (
Sister:
40 years old
No history of illness
or chronic disease.
)
7. Review of Systems
Patient says she weighs 165 pounds. She added that she
has not experienced any abnormal weight gain or weight loss.
She says she works on her weight by exercising almost every
day. Patient denies: fever, chills, sweat, or night sweat, but she
says she feels a little weak secondary to the persistent diarrhea
and abdominal cramps for two days.
Patient denies having eczema, change in skin color, rash or
lesion, mole, itching (pruritus), bruising, hives, but she
confirms having a history of dry skin in 2007, that was treated
with an extensive prescription body moisturizing cream
(Eucerine)which she still uses up to date.
Patient denies any type of hair loss, for example; patchy,
idiopathic, non-cicatrical hair loss and she accepts change in
her thin hair texture which was caused by her excessive use of

6. multiple hair relaxers in 2009. This was treated when she
stopped putted hair relaxers in her hair.
Patient refused a history of brittle or splitting nail, jagged or
late clubbing nails, and she says she doesn’t use nail polish
because of her occupation. She denies exposing herself under
the sun, and says she takes good care of her skin and makes sure
to deep condition her hair weekly.
Patient denies history of unusual headache, head injury,
dizziness, vertigo, or history of head surgery. When patient is
asked about her eyes’ condition,
She denied having pain in her eyes, no redness or itchy eyes, no
history of cataract or conjunctivitis, and no history of short
sighted or long sightedness. She doesn’t use glasses, and says
she always has yearly eye check –ups. In addition, patient
refuses having a history of ear pain, no ear discharge, or
reddish-blue discoloration, no history of tinnitus, or vertigo.
She says she uses a safe self-cleaning method to clean her ears.
She says she puts a few drops of mineral oil or water to soften
ear wax. This allows wax to come out easily.
Patient refuses having any history of nose discharge, sinus
problem, obstruction, epistaxis or allergy. She also denies
having frequent cold or change in smell, but she confirms
having a minor nose injury at age 12 years that was treated by
her pediatrician with pain medication. Moreover, patient denies
any history of sore throat or lesion, sore throat, bleeding gum,
tooth ache, hoarseness or voice change, dysphasia, and altered
taste. She also denies smoking and alcohol consumption. She
denies having lost any teeth or use of dentures and brushes her
teeth after every meal. She says she is up to date with her
dental follow-up appointments.
Patient denies neck pain. There is no history of lump or
swelling of the neck and no history of neck surgery or difficulty
turning the neck to both sides (ROM). No history of goiter or
lymph nodes.
When asked about her breasts, patient gives the following
information: denies pain in the breast, nipple discharge, lump or

7. thickness, rash, or swelling. She denies having any history of
breast disease or breast surgery. Patient states that she does her
breast self-examination monthly and does her mammogram
yearly. She just did one during her general physical exam on
August 15 2015 which came back normal. She says her mother
was diagnosed with breast cancer six years ago and was treated
with a series of chemotherapy.
Patient gives the following information about her
respiratory system when interviewed. She denies having any
history of chest pain or breathing difficulties, any history of
respiratory (lung) diseases or any form of COPD: Asthma,
emphysema, and bronchitis. She denies having any history of
pneumonia, tuberculosis, or pulmonary edema. She also denies
having any form of shortness of breath, wheezing or noisy
breathing, and cough. She also denies exposure to pollution
toxins. She refused smoking, and she says she works in a
smoke free environment. She says she had a TB skin test last
year that was positive and she was asked to do a chest x-ray that
came out normal.
Furthermore, patient denies chest pain, dypsnea cyanosis,
cough, fatigue, edema, or orthopnea, when she is asked about
her cardiovascular system. She denies any history of heart
diseases such as hypertension, heart murmur, anemia, coronary
artery diseases (CAD), and she says she just did her last ECG,
which was done on 15th August 2015 during her physical. Her
PTA result was normal. In addition, patient denies leg pain,
skin changes, coldness, numbness, or tingling of the extremities
when she was asked about her peripheral vascular system. She
denies swelling or enlargement of the lymph nodes. Patient also
denies presence of any peripheral vascular diseases:
thrombophlebitis, ulcers, and varicose veins. Patient states that
her nature of job permits her to sit and stands on intervals, and
she always has professional therapeutic shoes on.
On the gastrointestinal system patient gives the following

8. information when interviewed. She states that her appetite is
good with no recent changes, no food intolerance, no dysphasia,
heart burn, nausea, or vomiting. She denies having history of
gallbladder, jaundice, appendicitis, or colitis. Patient denies
any abdominal surgery, but she states that she has been having
diarrhea and abdominal cramping for two days after she
returned from a beach picnic. She states consistently has six to
seven watery non-tarry stool for two days, accompanied with
abdominal cramping and weakness. She says she has take some
over the counter (OTC) Imodium for diarrhea for two days
which didn’t help and that her reason for consulting.
Patient states that she has no problem with her urinary
system. She denies pain in the flank, groin, suprapubic region
or lower back. She also denies having history of UTI, kidney
stone, or kidney diseases. She stated that she never had a
history of dysuria, polyuria, oliguria, or staining narrow stream
urine. Patient states she always makes sure she does good
douching and uses clean bathrooms and bath tubs to avoid UTI
and doesn’t withhold urine voluntarily. She also uses kegal
exercises after birth.
Patient gives the following information about her genital
system. She states that she started menstruating (menarche) at
age 13years, and she has a 28 days menstrual cycle that lasts for
4 days with moderate flow and no pain or abdominal cramping
(dysmenorrhea). She also states that her last menstrual period
(LMP) was on the 28th of September 2015. Patient denies
vaginal itching or irritation, vaginal discharge, foul vaginal
smell, vaginal sore or lesion. She also denies pelvic surgery,
and she states that her last pap smear exam was done on August
15th 2015 during her annual physical exam and the result was
good. Patient added the following information about her
sexual health. She states that she is married, sexually active,
and has intercourse only with her husband. She denies pain
during sexual intercourse (dyspareumia), denies history of any
sexually transmitted diseases (STDs) like gonorrhea, syphilis,

9. herpes, and HIV/AIDS. She denies using any contraceptives.
As far as the musculoskeletal and neurological systems are
concerned, patient gives the following information. She denies
any joint pain, stiffness, or limitation on any joint. She denies
muscle pain or weakness. Patient states that she has no history
of bone trauma or deformity, arthritis, or gout. Patient states
that she is able to manage all her daily activities which include
cooking, house cleaning, grooming self, dressing, ROM with no
physical limitations. Patient also denies using any walking
aids. When asked about her neurological system, patient denies
any unusual frequent severe headaches, dizziness, head trauma,
weakness, numbness, tingling or difficulty swallowing or
speaking, and loss of sensory stimuli. Patient also denies
having any illness related to neurologic system such as seizures,
stroke, black out, fainting, mood change illness(depression), or
mental health illnesses (hallucination).
Moreover, patient denies having history of any hematologic
abnormalities. She denies anemia, bleeding disorder such as
hemophilia, blood clots, lymphoma, and myeloma. Patient also
denies exposure to toxic agents, and radiation. She also denies
history blood transfusion. Patient also denies any changes in
her endocrine system. She denies changes in skin pigmentation
or texture, intolerance to heat or cold, excessive urination,
hunger, thirst, or being sweaty (diabetic symptom). She denies
endocrine disorder diseases: Hyperthyroidism symptoms (hand
tremor, weight loss fatigue, or muscle weakness), Addison
diseases, or hypothyroidism.
Functional Assessment (Including Activities of Daily Living)
Patient states that she attended University of Yaoundé in
Cameroon, where she graduated with a 1st degree in history.
She also says she attended the University of District of

10. Columbia where she graduated as a License Practical Nurse
(LPN) . She is presently a full time RN student. Patient stated
she has worked as a home health aide and a GN, and she is
currently working as a fulltime LPN in a nursing home. She
adds that she is financially sufficient with the help of her
husband. She says her family lives a moderate healthy lifestyle.
She also continues that she believes in God and this provides
her strength, and she is a Roman Catholic Christian. Patient
stated that she is up to date with her doctor’s appointments,
enjoys exercising, eats healthy, and also has interest in learning.
Patient gives a rundown of her typical day off work as follows:
she wakes up at 8am, takes a shower and goes to school. She
takes a two hours nap after school. At 4 pm, she goes to the
gym for an hour and at 6 pm, they all eat dinner (husband and
kids) , then she studies for 4 hours and goes to bed at 11pm.
Patient also states that her husband helps with most of the
household chores. She also confirms that she does not need
help with her activities of daily living, for example; feeding,
bathing, grooming, etc.
Patient says she enjoys music, dancing, exercising, movies, and
reading during her leisure time. Patient states that her exercise
pattern consists of bike spinning 3 times a week with 30
minutes of treadmill warm up. She burns out about 500 calories
per session of exercise which her body tolerates very well.She
says that she takes at least 2 hours of nap time and 5hours of
sleep every night without sleeping aids.
Patient states that she eats a balanced diet, but tries to reduce
the amount of fat and carbohydrates intake. She says for
breakfast, she has cereal or oatmeal with skim milk, a cup of
juice or fruit, with a cup of coffee. For lunch, she has a ham or
chicken sandwich and drinks a lot of water. For dinner, the
family eats together food rich in vegetable and fiber. She has
no food intolerance and she is responsible for providing the
household with food.
Patient states that she was brought up by her religious and God-
fearing parents. She experienced a quiet family life with her

11. mom, dad, and 2 siblings. She states that she gets acquainted to
people easily and she is very outgoing and can deal with any
personality. She has a good marital relationship with her
husband, as well as a good relationship with her friends and
coworkers. She avoids people who want to influence her
negatively. She also states that she has a strong support system;
her husband, friends and family, coworkers, and classmates are
always there for her when she needs help. She says she spends
5 hours a day to nap or study in a quiet place. Patient confirms
that she is stressed with school assignments and becomes
anxious during exams. In order to cope with this she uses the
following methods to relieve her stress: relaxation, positive
thinking, healthy eating, and regular exercise. She thinks these
methods work for her.
She doesn’t smoke, doesn’t drink alcohol, denies using drugs
such as marijuana, crack cocaine, heroin, or barbiturates. She
added that she lives in a single family home with adequate heat
and utilities with her husband and 3 kids. She states it is a drug
free, environmental hazard and chemical pollution free zone.
Patient denies any environmental hazards and says she uses
safety measures when in a car by putting on her seat belt and
also has easy access to transportation. She says she and her
husband each own a car and also have bus stops in their
neighborhood. Patient accepts residing in Cameroon but denies
ever being in the military.
Patient says she has a lovely and safe married life with no
incidents of abuse from her husband. She denies physical or
sexual abuse from her husband and says her husband is her best
friend. She says she is an LPN nurse, working in a nursing
home. She denies working with hazardous chemicals. She adds
that she enjoys helping patients but she gets emotional when
patients are suffering and are in their dying stage.
Patient states:“Health is a state of complete physical, mental,
and social wellbeing and not merely the absence of disease or
infirmity”. Again, patient says she is very persistent about
having her breast exams because her mom is a survivor of breast

12. cancer. She also says given her healthy lifestyle, she doubts
she’d have chronic illnesses. She concludes that she expects
nurses and physicians to promote healthy lifestyles and focus on
disease prevention rather than treatment.
Reference
· Physical examination and health assessment by Javis
· How to clean out your earsproperly/upmc healthbeat
http://www.bing.com/search?q=share.upmc.com&form=IE10TR
&src=IE10TR&pc=CPNTDFJS
· How do you define health www.who.int/definition
·
Holistic Assessment/Variable Paper: Due on November 13, 2015
To complete a holistic/variable assessment, utilize the same
person that you obtain a health history from to perform an
assessment of variables. Assessment of the variables provides a
holistic view of the client and which attribute to their overall
health. The variables assessed are to be as follows:
· Developmental – includes physical and cognitive development.
Document stage of development that your patient is currently
experiencing (i.e. integrity vs. despair); describe the stage of
development that your patient is in and why this whole
development stage is important to nursing care. References two

13. peer reviewed articles on development.
· Sociocultural – includes your patient’s culture. What values,
heritage, and culture he or she is practicing or adhering to from
their culture. How does your patient socialize? i.e, having
family visits every week, month etc., what culture environment
does your patient reside in, Chinatown etc. Explain why the
patient’s sociocultural background is important to the nurse in
relationship to delivering nursing care. Chapter 2 – Jarvis
textbook . References two peer reviewed articles on
Sociocultural impact on delivery of care.
· Spirituality – includes your patient’s religion, religious
background, and spiritual well-being. Explain why the nurse
needs to know this information in order to provide nursing care.
Chapter 2 – Jarvis textbook. includes your patient’s religion,
religious background, and spiritual well-being. Explain why the
nurse needs to know this information in order to provide
nursing care. Chapter 2 – Jarvis textbook. References two peer
reviewed articles on Spirituality effects on patient physiologic
well-being.
· Psychological – includes your patient’s orientation, mood and
affect, ability to respond and carry on a conversation with you.
Explain why the nurse needs to know this information in order
to provide nursing care. Chapter 5 – Jarvis textbook .
References two peer-reviewed articles on the effect of
psychological health on physiologic well-being.
The paper should be in APA format 6th edition. Therefore, it is
highly recommended that you purchase this book in order to
complete this assignment. Please proof read your paper prior to
submission to ensure you have completed a spell check,
grammar check and the paper is in the correct format, this
section counts for 10% of your paper. Visit PurdueOWL or
APAstyle.org for assistance
You MUST HAVE ATTESTATION from the writing center that
your work was reviewed by them. You need to schedule an

14. appointment with the writing center by emailing Kelley
Coleman at [email protected] or by telephone at 703-212-7410 x
5241.
Assignments shall only be submitted electronically via
SonisWeb at 5:00 pm. Assignments turned in beyond this
specified time will earn “Zero.” Students found to have
committed acts of academic dishonesty such as plagiarism will
also receive zero.
Holistic Assessment/Variable Paper Grading Rubric
Beginning
Developing
Exemplary
Developmental Assessment (20%):
Missed two or more of the components stated to receive
exemplary.
5 points
Missed one of the component stated to receive exemplary.
10 points
· Discusses physical and cognitive development.
· Documents stage of development that your patient is currently
experiencing
· Describes the stage of development that your patient is in and

15. why this whole development stage is important to nursing care.
· References two peer reviewed articles on development.
20 points
Points
Beginning
Developing
Exemplary
Sociocultural Assessment (20%)
Missed two or more of the components stated to receive
exemplary.
5 points
Missed one of the component stated to receive exemplary.
10 point
· Includes your patient’s culture. What values, heritage, and
culture he or she is practicing or adhering to from their culture.
· Include how your patient socializes.
· Explains why the patient’s sociocultural background is
important to the nurse in relationship to delivering nursing care.
· References two peer reviewed articles on Sociocultural impact
on delivery of care.
20 points
Points

16. Beginning
Developing
Exemplary
Spirituality Assessment (20%):
Missed two or more of the components stated to receive
exemplary
0 points
Missed one of the component stated to receive exemplary.
10 points
· Includes your patient’s religion, religious background, and
spiritual well-being.
· Explain why the nurse needs to know this information in order
to provide nursing care.
· References two peer reviewed articles on Spirituality effects
on patient physiologic well-being.
20 points
Points
Beginning
Developing
Exemplary
Psychological Assessment (20%)
No functional assessment was completed

17. 0 points
Missed one of the component stated to receive exemplary.
10 points
· Includes patient’s orientation, mood and affect, ability to
respond and carry on a conversation with you.
· Explains why the nurse needs to know this information in
order to provide nursing care.
· References two peer-reviewed articles on the effect of
psychological health on physiologic well-being.
20 points
Points
Beginning
Developing
Accomplished
Exemplary
Grammar, APA format and references (10%)
Grammatical errors present consistently throughout the paper.
AND
Incorrect formatting and referencing
zero
Grammatical errors present for the most part of the paper.
AND
moderate errors in formatting and referencing
5points

18. Grammatical errors present in less than a half of the paper.
AND
moderate errors in formatting and referencing
7 point
Minimal or no grammatical error present throughout the paper.
AND
no errors in formatting and referencing
10 point
Points
Beginning
Developing
Accomplished
Exemplary
Attestation (10%)
An attestation was not attached or student lied about seeking
help from the writing center.
Zero
Attestation is present and help is verified.
10 points
Points

19. Beginning
Developing
Accomplished
Exemplary
Total Points
Final Grade
Comments