Prof. Name Date

Demographic Data

L.S. is a 23-year-old Caucasian woman born on February 4, 1993, in Baltimore, Maryland. English is her primary language, though she has a basic understanding of Spanish. She completed her high school education in 2011 and now resides in Salisbury, where she balances her studies with a job as a veterinary receptionist/technician. L.S. currently lives with her boyfriend and his parents while saving to move out independently. She reports experiencing frequent headaches.

Health Perception

L.S. recognizes her obesity but is actively working on her physical health. She reports being mindful of her dietary habits and has taken up running regularly as part of her training for an upcoming marathon. Despite viewing herself as overweight, L.S. generally considers her health to be good and is highly focused on maintaining her current regimen to prepare for the marathon, which is scheduled in a few months.

Past Medical History

L.S. occasionally consumes alcohol on weekends when not working but is a non-smoker. She has no history of hospitalizations for significant health issues. However, she was previously diagnosed with shin splints, a condition that emerged during her high school soccer activities. For her headaches, L.S. takes 200 mg of Ibuprofen as needed for relief.

NR 302 Health Assessment I Health History RUA paper

Category Description Details
Family History Paternal Grandparents Both are high school graduates. Grandfather, a retired firefighter, was diagnosed with diabetes at 73 and suffered a heart attack at 75. Grandmother, also retired, had spinal surgery in 2015 but remains in good health otherwise.
Maternal Grandparents Deceased. Both were high school graduates. Grandmother had a history of smoking until 25 and died of lung cancer due to poor circulation. Grandfather was a Navy Seaman and a heavy drinker who passed from bladder and prostate cancer.
Parents and Siblings Mother holds a Bachelor’s Degree, works as an IT Manager at the U.S. Census Bureau, and has no significant health issues. L.S.’s father, a Bachelor’s degree holder, works as an IT Specialist with the Department of Defense and has hypertension, obesity, pre-diabetes, migraines, and chronic sinusitis. One brother had a heart attack at 41, followed by colon and liver cancer diagnoses at 58. Another brother has type 2 diabetes.

Review of Systems

The interview with L.S. was conducted at a local coffee shop, providing a relaxed and comfortable setting for the discussion. L.S. appeared at ease and willingly responded to questions, making the interaction smooth. Although I initially felt slightly nervous, my preparation and application of class knowledge facilitated the process effectively. A casual conversation over coffee allowed us to build rapport, which fostered a level of trust that enabled L.S. to be open with her responses. While I gathered the necessary information, I noticed that I relied on closed-ended questions more than intended. Moving forward, I aim to incorporate more open-ended questions to encourage deeper discussion.

Reflection

The interview with L.S. was insightful and engaging. Conducted at her preferred coffee shop, the setting was comfortable, and L.S. felt at ease, which contributed to the openness of our conversation. Although I initially felt some nervousness, organizing my questions and applying what I had learned in class helped the interview proceed smoothly. The coffee shop setting allowed us to establish trust and rapport, which facilitated open communication. Although the trust built easily, I recognize that future interviews may not progress as smoothly, and I will be prepared to adapt as needed. I realized that I relied heavily on closed-ended questions and aim to use more open-ended questions in the future to promote more elaborate responses. Following the interview, I recommended that L.S. seek additional information about diabetes and nutritional values, and she showed genuine interest in understanding these topics better to support her long-term health.