Health History and Physical Examination of an Individual

Health Assessment
Student’s Name
Institutional Affiliation
Course Code and Name
Instructor’s Name
Due Date
Health History
The person is a fifty-year-old female who is African American. She is a cook by profession, and she says that business has been good of late, and her earnings have increased over the past three months. She has three children who she all sees through college all alone after the death of her husband three years ago. She has not been feeling so well recently, and she thinks her health has deteriorated since she added weight (due to increased appetite and inactivity). She has been feeling extremely dizzy, especially after meals, and has blurred vision, extreme thirst, and frequent urination. Apart from the symptoms she has been experiencing, she has no other state of concern. She explains that when she notices the symptoms, she takes paracetamol 500mg and takes a little nap, only to wake up fine. She admits that she needs to seek healthcare as soon as possible, to alleviate her gut feeling that her symptoms could mean something more severe than it feels. She has not had any other health concerns in the past, nor does she have an allergy. Ten months ago, she received covid-19 vaccination, which went smoothly. She explains that her parents had no health issues and died in a road accident. However, she remembers that her grandmother from her father's side had diabetes and hypertension, and she spent most of her last days on unsuccessful medical therapy, leading to her death.
Under the review of systems, she explained that she had gained massive weight, approximately twenty kilograms, in the past nine months. She has been having blurry vision and no problems with the ear, nose, and throat. Her skin has had no notable change or problem. She explains that she has had no chest pains, edema, or palpitations. She has had no shortness of breath or coughing. She has not had diarrhea, vomiting, pain in the abdomen, or blood in the stool. Using Erickson’s psychosocial development stages, the patient is at the seventh stage, Generativity vs. stagnation. She has been striving to develop a good relationship with her children, committed to her job, and is a mentor to many. She believes that by doing so, she will leave the world in a better place when death catches up with her. Therefore, she has met all the milestones for that stage. She lacks cultural alignment and believes in contemporary medicine and modern approaches to healing and vitality. She is a Christian who believes in miracles, and it gives her peace knowing that whatever her health issue is, she will make it through strong due to divine intervention. Her children are her greatest psychological support. There are several healthcare facilities in her town, and she is at ease knowing that such a collaborative resource will greatly help her.
Objective Data
On closely examining her under HEENT, she has retinal vein occlusion. She has no problems with her ear, nose, or throat. Under the neck, her thyroid and lymph chains were normal (no significant finding). There was significant finding over the respiratory...