The individual selected for this health history assignment is T.T., a 51-year-old woman. T.T. was born and raised in southern Illinois and moved to northern Illinois at 22 to start a family. After getting married and having two children, she remained in northern Illinois until her divorce in 2007. 2017 T.T. remarried, and her current husband has three children from a previous relationship. Together, they have five grandchildren. T.T. initially worked as a waitress and bartender in northern Illinois but later transitioned to an office manager at a high-performance and custom engine manufacturing company.
Perception of Health
T.T. acknowledges her limited health literacy and understands that it may affect her perception of her health. Nevertheless, she generally believes she is healthy for her age. T.T. feels capable of performing all the activities she has done in the past and maintains a consistent level of energy. Despite having a chronic illness, she believes that her health is well-managed. Overall, T.T. views her health as good and attributes it to living a healthy and fulfilling life.
NR 302 RUA Health Assessment I
Past Medical History
When asked about her medical history, T.T. states she has lived without many illnesses. However, she has a history of asthma, which she has managed for the past 44 years. T.T. controls her asthma with a daily inhaler and occasionally uses a rescue inhaler or breathing treatments during exacerbations. She recalls a previous hospital admission for diverticulitis and expresses discomfort when reminded of the pain she experienced. In 2019, T.T. was diagnosed with malignant melanoma after noticing an unusual-looking mole on her upper back. She underwent two surgeries to remove the cancerous skin and has been cancer-free since the last surgery. Additionally, T.T. has undergone two Cesarean sections, one performed as an emergency. She used to smoke regularly for 15 years but now only engages in social smoking and drinking. T.T. ensures she receives the influenza vaccine annually and stays updated
Family Medical History
When asked about her family’s medical history, T.T. has limited knowledge about her father’s side of the family. She knows that her father and several of his relatives were coal miners and suffered from lung disease. As for her mother’s side, T.T. lacks detailed information as her biological parents did not raise her. However, she was raised by members of her maternal family who shared some insights. T.T. learned that her aunt had also been diagnosed with melanoma, the exact condition she faced. Additionally, her grandmother currently lives with dementia. T.T.’s mother, aside from alcohol dependence, does not have any known medical conditions. T.T. has no siblings, and her children are healthy and
NR 302 RUA Health Assessment I
Review of Systems: Skin, Hair, and Nails
Regarding the skin, T.T. discloses her history of malignant melanoma. She noticed a black-colored mole with an irregular border on her upper back and promptly sought the expertise of a dermatologist. The dermatologist performed a thorough examination and recommended a biopsy. T.T. is grateful that only one spot raised concern for the dermatologist. The biopsy confirmed the presence of malignant melanoma, leading to immediate surgery for its removal. Following the initial surgery, a subsequent biopsy revealed the presence of residual malignant cells, necessitating a second and final surgery. T.T. is relieved to report that it has been one year since the last surgery, and she has been declared cancer-free.
Jarvis, C. (2019). Physical examination & health assessment. St. Louis, MO: Elsevier. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2017). Fundamentals of nursing. St. Louis, MO: Elsevier.