[Institution Title]
Health History and Screening of an Adolescent
- Biographical Data
Patient T.M., female is 14 years old. She weighs 103 lbs and stand 5 ft. 5 inches. TM is the only child of her parents who were both in their mid-forties when she was conceived. This is the reason her parents were overprotective of her. TM is not allowed to go out to parties or sleep overnight at a friend’s house. However, TM is pampered with everything she wants. Her parents buy her everything she wants, and she gets to enjoy vacations with her parents overseas. TM smokes cigarette every time no one is around. She tried to experiment with drugs once, but she did not like the effect, so she quit.
- Reason for Seeking medical attention
Patient reports palpitation, cramps and nausea for five days. Patient TM does not like to eat anything except for cereals and lemon juice.
During physical assessment, TM’s temperature was 37.4°C. Her blood pressure was recorded at 130/90. RR = 20 breaths per minute. PR = 123 bpm
- Past Health History
TM was hospitalized twice for asthma when was 11 years old and once for allergic reaction to penicillin. Patient has bronchial asthma beginning from when she was three years old. Patient is also Type II diabetic where patient experiences frequent lowering of her blood glucose level (Diabetes Organization, 2014). She was diagnosed with this type of diabetes after she collapsed at school when she was 12 years old. During this time, TM had been skipping meal because she thinks she was too fat. Her parents sent her to see a child psychologist who said that TM was suffering from a condition known as body dysmorphic disorder. It is a type of dysfunction where the person believes that her physical appearance is defective and requires fixing (Ahmed, 2014). While TM weighs 83 lbs at 5’4”, she still believes that she was fat. After three months of counselling and the support of her family and friends, Patient TM was able to recover from the disorder.
Aside from an allergy to penicillin, TM is also allergic to shrimp and crabs. She takes ascorbic acid regularly and ferrous sulfate because her menstruation tends to be too heavy (8 to nine pads/day) while her period usually last for six days to a week and three days.
- Family History
TM’s father is Type I diabetic. He also has hypertension and was diagnosed with ERD two years ago. At present, her father is undergoing dialysis every two weeks. TM grandfather from her father side died of cancer of the kidney when TM was still two months old. Her grandmother, on the other hand, has Type I Diabetes, hypertension and asthma.
On the other hand, TM’s mother has hypertension that only developed during her pregnancy with TM. On her mother’s side, most of her uncles along her grandparents are all hypertensive.
- Review of System
1. Neurological – Patient seems agitated. Responses to questions seem aversive, and she fails to develop eye to eye contact when answering.
2. Respiratory – Patient is breathing heavily. However, there seems to show no indication of fatigue or breathing difficulty. Moreover, seemed to show shortness of breath as though that the patient is nervous.
3. Cardiovascular – Patient reported palpitation confirmed by the PR of 123 bpm. Patient’s blood pressure was also abnormally high at 130/90.
4. Gastrointestinal – patient has become selective of the food she eats. She only likes to eat cereals and lemon juice. Her mother said this is not usually the case with her daughter who was a “hearty eater.” Upon palpation, patient’s abdominal area was hard around the lower section of the stomach.
5. Genitourinary – patient reports to urinate frequently now as she used to. However, she said it is because she’s been drinking a lot of fluid lately.
6. Integumentary – patient’s skin is intact. No lesion, bruise or rashes.
7. Musculoskeletal – patient has not reported any limited movement or pain in her joints.
8. Endocrine – patient reports are experiencing excessive thirstiness that is the reason for her increased fluid consumption and frequent urination.
9. Reproductive – patient reported that her menstruation is very irregular, and this was confirmed by her mom. This month, her menstruation was already delayed by three days. When asked if there is any reason to suspect that the patient could be pregnant, patient said no. A pregnancy test confirmed that the patient was not pregnant.
Nursing Diagnosis
- Patient is suffering from an eating disorder. The patient has been refusing to eat accordingly because she fear that she is getting too fat also known as anorexia nervosa (WebMD , 2014) This is the basis why she has been limiting her food consumption to just cereals and lemon juice. Her history of body dysmorphic disorder is similar to this condition, and this could well be the start of this condition as well.
- Patient has a very poor concept of self. She is very sheltered and not sociable. As a result, her concept of beauty and friendship has been isolated to her misconception of beauty. TM seems to believe that people like individuals who are pretty and sexy. She gets this from what she sees on TV and rom her experiences at school where overweight and obese students are isolated.
- Patient is at risk for the psychological condition known as “anorexia nervosa.” In addition, patient might also fall under depression she continues to experience dissatisfaction of her weight. This is because her wrong perception of dieting significantly affected her eating and her nutrition. As a result, other medical condition might arise like hyper-acidity from drinking lemon juice despite being hungry.
References
Ahmed, I. (2014, August 4). Body Dysmorphic Disorder. Retrieved from Medscape Website: http://emedicine.medscape.com/article/291182-overview
Diabetes Organization. (2014, November 2). Basics on Type 2 Diabetes. Retrieved from Diabetes Organization: http://www.diabetes.org/diabetes-basics/type-2/
WebMD . (2014, November 2). Anorexia Nervosa Health Center. Retrieved from WebMD Website: http://www.webmd.com/mental-health/eating-disorders/anorexia-nervosa/anorexia-nervosa-topic-overview
