Comprehensive Health Essays

732 Words Jan 15th, 2016 3 Pages
Comprehensive Health Assessment
September 17, 2013

9/17/2013 15:30 PM

S:Mrs. Easter is a pleasant, but very anxious, 32 year old married mother of 2 residing in Houston, TX and is an Executive Administrative Assistant and business owner.
Referral: None
Reliability: Self-referred; seems reliable.
Chief Complaint:Patient complained of “shaky hands”
Present Illness: For the past year Mrs. Easter has had a problem with unsteady hands and palpitations in her heart. She was seen in the emergency room one month ago due to what she felt was a possible heart attack at the time. The emergency room physician diagnosed a panic attack and possible Generalized Anxiety Disorder. She has also had recent episodes of blurred
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Patient was married at 29 years old. It is the only marriage patient has had. Patient was involved in a car accident in 2009 and struck the front of head and back of head on dashboard and windshield, patient reports hospital found no injuries. Patient has only a few select “friends” and rarely attends any social events. Patient works as an Executive Administrative Assistant to the owner of a construction business in Houston, and also owns and operates an energy business. Patient has very little free time and the time she has is filled with church obligations. She feels stressed that “there is never enough time.” * Exercise and diet. Patient reports moderate exercise. Patient reports diet high in carbohydrates and low in fat.

Review of Systems:
*General. Patient reports she has gained 5 lbs. in past 4 years.
Skin. Patient denies rashes or other changes in the skin.
Head, Eyes, Ears, Nose, Throat (HEENT). See Present illness. Patient denies history of head injury. Patient denies any blunt hits to the head. Patient denies any bouts of unconsci Eyes: Reading glasses for 6 years. Last checked 2 years ago. Eye infection due to allergies 1 year ago, treated with Vigamox. No reoccurrence.Ears:see Childhood Illnesses. Patient denies any current issues. Nose, sinuses: Season allergies, exact allergens are unknown. Sinus clear. Throat: Patient denies any symptoms.
Neck: Patient denies lymphs, goiter, and pain. Patient reports no swollen

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