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Report Example: Client's Health History

5 pages
1186 words
Middlebury College
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The family has a history of Obesity, hypertension and Parkinson's disease. Patient (LM) used to smoke and drink alcohol. Participated in exercise but not on a regular basis. Her husband passed away a few months before she was admitted. Her healthy lifestyle ensured that she had been ill very few times when she was younger.

Pathophysiology of primary diagnosis

Physiological Integrity

Major depressive disorder is often known to showcase different clinical and etiological characteristics for different patients. The common pathophysiological examinations are based on neurobiological theories supported by their strengths and weaknesses evaluation. Pathophysiology of the Major depressive disorder is aided by psychosocial integrity, stress hormones, and study of neurotransmitters such as serotonin and dopamine. Another significant indicator is also the sleep patterns which depend on circadian rhythms (Hasin, Goodwin, Stinson & Grant, 2005).

The patient (LM) shows signs of depression such as trouble in concentration, restlessness, fatigue, persistent pains, and memory loss (Nelson & Charney, 1981). Other signs of depression include digestive problems which the patient has in the form of constipation. She reported lack of bowel movement for two days despite lack of pain when the abdomen is palpated. Considering that LM is a 93-year-old with a previous diagnosis of hypertension, a current BP of 138/61 is a good improvement from 175/72.

Psychosocial integrity

According to LM, it was tough to adjust to the new environment due to the loss of independence. Her strong will has enabled her to fit well. Initially, she was afraid of surgery to fix her fracture. Currently, she is okay with the treatment she is getting.

Clients affect

LM is a flexible and reasonable person, but at the same time, she is very emotional. When talking about her husband and their memories together, she sheds tears. She even admits that she used to be sad and cried more times when first transferred to the facility, but as time has passed, she has made friends and is feeling better.

Coping mechanisms

She takes part in all the activities like going to the salon to have her hair and nails done. Spends time with other people in the facility. Her daughter visits her every Friday and she, therefore, feels loved.

Compliance with health care plan

She likes to follow up on the results of physical therapy sessions, labs, and x-ray. Even though she takes time with activities of daily living, she is willing to do them herself with minimal help. She is also responsive when asked questions by the aid.

Cultural considerations

Clients preferences unique to culture: hygiene, diet support

LM needs help with daily ADLs such as eating and dressing. The health aid helps her with the bath every Monday and Friday. She likes to spend time with the assistant and share some feelings with her.

Role: marital status, children, parents, etc.

LM is 93 yrs. old. She was married to her husband for 52 yrs. She has six kids, four sons, and two daughters. Her husband owned a pharmacy store, and she was a homemaker. She lived a happy life and always busy raising kids. LM and her husband traveled a lot and enjoyed spending time with family. All her kids are married and have families meaning she has grandchildren. LM is so happy that she and her husband were able to provide a good life to their children and gave them a good education. Her illness results from the death of her husband with whom she used to engage in many activities together, hence her current loneliness.

Spiritual state

LM has a strong Christian faith. She states that she has always enjoyed attending church proceedings, but now since she is in the facility, she cant go to the church every Sunday.

Clients statements that reflect joy/purpose of living vs. hopelessness

She is pleased with the way she lived her life. Losing her husband makes her hopeless. And she wished for more physical independence so she would be able to do all ADLs without anyone's help and to go out.

Clients inner strength/weaknesses

Her family is her strength and losing her husband was the saddest thing in her life. Staying alone makes her sad but when her family visits her that makes her happy.


As per Eriksons Developmental Stages, LM falls under the ego integrity vs. despair level. This applies to persons over the age of 65 and is shown by how the patient contemplates her past life. She is happy that she and her husband were able to provide a good education for all the kids. On the other hand, she despairs over the death of her husband.

For LM, it is unusual for her to stay in the facility and to be taken care of. This is because she had gotten used to taking care of her husband and her kids. She also felt capable of performing daily activities, but the pains on her back and leg could not allow. The role changes were unfamiliar to LM.


Relocation from Seattle to St. George, then losing her husband and being admitted to the facility. In her earlier parts of her life, she was used to having her four children, but all are now married and living elsewhere.


She never had major health problems when she was young. But she started having health problems after 70. Luckily she has strong financial savings, so she doesnt need to worry about the expenses. She has good health insurance. It is just hard for her to stay in the facility away from family.

Significance of Assessment Findings

Upon admission, it was evident that the patient, LM had high blood pressure. The cardiovascular report based on the latest examination shows an improvement from 175/72 to 138/61. This result is based on medications undertaken as well as the patients mental status. The mental status and mood changes of the patient when at the facility indicate nervousness and anxiety during her first few days of admission. Later on, she was able to accept her situation and remain relaxed and comfortable at the facility (Carney et al. 1988).

The physical examination which deduced back pains and leg pains support the diagnosis of the major depressive disorder. The tiredness and shortness in breathing results in fatigue which in the end creates hopelessness in the patient. For LM whose history is one filled with adventure, she was stressed that she could no longer walk long distances and perform chores on her own. From the assessment findings, major depressive disorder is evident and is the reason for memory losses (Belmaker & Agam, 2008). The best solution for this case is to make the patient feel as if the facility is her home.


Belmaker, R. H., & Agam, G. (2008). Major depressive disorder. N Engl j Med, 2008(358), 55-68.

Carney, R. M., Rich, M. W., Freedland, K. E., Saini, J., Simeone, C., & Clark, K. (1988). Major depressive disorder predicts cardiac events in patients with coronary artery disease. Psychosomatic Medicine, 50(6), 627-633.

Hasin, D. S., Goodwin, R. D., Stinson, F. S., & Grant, B. F. (2005). Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Archives of general psychiatry, 62(10), 1097-1106.

Nelson, J. C., & Charney, D. S. (1981). The symptoms of major depressive illness. Am J Psychiatry, 138(1), 1-13.

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