Health History and Screening of Adolescent

Health History and Screening of Adolescent Introduction Health screening is a strategy used to identify or detect unrecognized diseases in individuals before they start showing symptoms. These screens are intended to identify disease in the community at an early stage such that measures are taken to manage and contain them with an aim of reducing suffering and mortality (Center for Disease Control, 2012). In this paper, we are going to conduct a health history and screening on a young adolescent adult.
Biographical Data
Patient Initials: T.R. Phone No: +1-34-58748
Address: 5785, Massachusetts
Birth Date: 09/11/1990 Age: 25 Sex: Female
Birthplace: Illinois Marital Status: Single
Ethnic Origin: American
Occupation: Student, Massachusetts College
Financial Status: Low income
Present Health or History
General Health: Feels tired because of vomiting.
Reaction: None
Current medications: None
Last Exam Date: June 10 2012
Immunizations: all immunizations are up to date
Childhood illness: chickenpox when 8 years old
Serious or Chronic illness: None
Past health Screening History
Past Hospitalizations: Admitted 3 months ago because of voting food poisoning
Past operations: None
Family history
Allergies: None
Asthma: None
Arthritis: None
Blood Disorders: Sister
Breast Cancer: None
Cancer (other) None
High Blood Pressure: Father
Kidney Disease: Sister
Heart Disease: None
Obesity: Brother
Tuberculosis: None
Obstetrics History:
Gravida: None Preterm: None Ab/incomplete: None
Well Young Adult Behavioral Health Screening History
Socio-Demographic Questions and Content:
What activities or organizations are you involved in? (Church, profession, sports, school)
How do you regard your community? I live in rental house in town. It is a good neighborhood with many business people.
What are skills, hobbies, and interests? Reading, playing football, listening to music and hiking
Any family member who has last 3 months: None
Military service: Yes_______ No__X_____
Marital status: Single____X__ Married________Divorced_________Separated_________
In serious relationship_____Yes___ Length of time_1 month_
Have you worked before? No, I am in college and will finish the end of the year.
Chief Concern:
What is your chief complaint? I like coming for checkups after every 3 months to check on my overall body condition.
Review of Systems
General: I have gained 1 kgs in the last 3 months.
Respiratory: None
Cardiovascular: None
Homoeotic: I donate blood back at college last month.
Nursing Diagnosis:
Actual Diagnosis:
Patient has fluid deficit caused by vomiting. She has been trying rehydrating herself by taking pedialyte. However, her skin shows no symptoms of dehydration but the lips are dry and cracked.
Wellness Plan
Patient is on pedialyte to avoid dehydration. She has also promised to visit a dietician to recommend appropriate foods her.
At risk diagnosis
Patient has not been taking diet rich in vitamins to help boost her immunity. With the cracked and dry lips, the patient can get an infection. patient is thus advised to maintain general body cleanness to avoid infection.
References
Center for Disease Control. (2012). Key statistics from the national survey of family
growth. Retrieved from http://www.cdc.gov/nchs/nsfg/abc_list_i.htlm [Accessed: 17 March 2014].