Health History and Assessment: Case Study Template

Health History
Gender Female
Age 52 years
Current Medical History
I am 52 years old with the medical history of diabetes for 8years and I am on
anti diabetic medications. I am suffering from hypertension for the past 6 years
and it is managed with the diet only. Last year, My husband passed away in an
accident which made me undergo severe depression. I am on antidepressants
and recovering now.
Past Medical/Surgical History Medical History
I had meningitis when I was eight
years and recovered with
hospitalization and medication. Has
no history of recurrence.
Surgical History
I had two caesarean section surgeries.
Medications List medications and dosages
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Tab. metformin 500 mg twice daily
Tab. Vortioxetine hydro bromide 20mg once daily
Do you live alone/with someone? Alone
Are you able to care for yourself?
Do you need help with showering?
Do you need help with toileting?
Do you need help with dressing?
No
No
No
No
Do you have a vision impairment?
Do you wear glasses?
No
No
Do you have a hearing
impairment?
Do you wear a hearing aid?
No
No
Do you wear dentures? No
Do you drink alcohol?
How often do you drink?
How many drinks do you have
each day?
Yes
daily
5-6
Do you smoke?
How many cigarettes do you
smoke a day?
Yes
2-4
Do you follow a special diet?
What is the special diet?
What is your height?
What is your weight?
Yes
Diabetic and low sodium diet
160 cms
46 kgs
Do you have any mobility issues?
Do you use a mobility aid?
No
No
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Do you do any exercise? I used to go for an evening walk with my neighbour
Do you have any wounds?
Where are they?
Yes
The diabetic wound in the left foot which causes pain
Beck depression inventory The result – 26 which represents moderate depression (Knaster, 2016).
Alcohol Use Disorders
Identification Test
The result – 28 which represents that she needs detoxification and deaddction
treatment (Bodell, 2017).
MUST assessment tool The result – Score 1 which indicates that she is on moderate malnutrition
(Bodell, 2017).
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Assessment 1 – Case Study Template
1) Consider the Individual
The person I interviewed was a woman. She is 52 years old suffering from diabetes and hypertension. She is also suffering from
moderate depression. She is on antidiabetic and antihypertensive medications.
Current information
As a result of the loss of her husband, she had become addicted to alcohol and smoking. She has made few friends
from her neighbourhood. None of her relatives visits her or phones her. Beck depression inventory is the assessment
used by the nurse to rule out the level of depression in a person (Knaster, 2016). This is a self-scored assessment
that allows the person to answer the questionnaire independently. On assessment she scores 26 in the Beck
depression inventory which indicates that she is suffering from moderate depression.
She has started drinking alcohol and the habit of smoking recently due to depression. One of the typical symptoms
of depression is lack of appetite. As a result of less food intake, she had undergone a nutrition deficit. She weighs
46kgs and looks weak. She is not showing interest to improve her food intake. MUST is the assessment tool which
measures the level of malnutrition based on the weight loss. On assessment she scores 1 which indicates that she is
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