Chamberlain College of Nursing NR305 Health Assessment
Milestone#1: Form for Health History
BIOGRAPHICAL DATA (10 pts)
Date of birth:
20th February 1973
Source of information:
The patient competently provided the information required during the Interview. He gave the data clearly and confidently
Reliability information source:
He was able to articulate the information clearly and comprehensively. The information provided was reliable.
PRESENT HEALTH HISTORY/ILLNESS (15 pts)
Reason for seeking care:
Chest pains for 3 hours, restlessness all day, He wants to begin exercising and requires check up.
`The patient was in a poor health state until four days ago. During that period he had SOB with stiffness in the chest. To make breathing easier he has been using albuterol MDI 2 inhalation qid. Yesterday he had a sore throat, fatigue, sputum, nasal discharge and a body temperature of 37.2⁰C. The symptoms started the day after he carried out yard work.
He wants to be health so that he can play well his managerial role and also carry out exercises
HEALTH BELIEFS AND PRACTICES (15 pts)
Beliefs and practices:
He believed in blessings before a surgery. If he is sick he believed that he should be offered sacraments. He would also request holy communion prior surgery. He also believes that stray cats cause diseases
healthcare decisions influencing Factors:
Food belief and diet, beliefs about causes of illness, views on health.
Related traits, habits or acts:
He believed that injections work better than oral medicine.
MEDICATIONS (15 pts)
One week ago he received medications on severe headaches and tooth aches.
He received OTC medications to control headaches and toothaches.
He used herbal medicine to calm the tooth ache pains
PAST HISTORY (15 pts)
He suffered from common diseases such as common cold. He did not suffer from any major childhood disease
BCG at birth, DPT, OPV, AMV, TT, HBV, Influenza vaccine.
Food- allergic to red meat.
Drugs- catecholamic drugs,
Environmental allergens- not allergic to any environmental allergens.
He has never transfused blood
Suffered no major illness
Suffered only minor back injuries after he fell in his compound
The patient has never been hospitalized
Labor and deliveries:
No surgeries ever carried out on the patient
Use of alcohol:
He is an alcoholic and drinks every weekend. He was also diagnosed with cirrhosis
Use of tobacco:
The patient does not use tobacco
Use of illicit drugs:
He uses no illicit drug
EMOTIONAL HISTORY (15 pts)
Mental, psychiatric, or emotional problems:
He has not suffered any psychiatric conditions, from his lineage there is no trace mental illness condition
FAMILY HISTORY (15 pts)
(Duraiswamy et al, 2011)
Died at the age of 68 years.
Cause of death- high blood pressure.
Aged 64 years.
Health condition-she is in good health condition but for last one year she has been suffering from asthma
Aged 34 years.
Health status-he is in a healthy body status.
Died at the age of 76 due to blood pressure
PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts)
(Basham et al, 2016)
The patient began his career as a restaurant attendant he was later promoted to an assistant manager at the restaurant. Due to outstanding performance as an assistant manager he was promoted to be the manager.
Highest level of education was the college level.
He is a middle class income earner, living an average life.
ROLES AND RELATIONSHIPS (15 pts)
(Barnett et al, 2012)
Has close relationship ties with his family and he is the sole bread winner.
All support system functioning normally.
ETHNICITY AND CULTURE (10 pts)
Ethnicity and culture:
He is not affiliated to any ethical group. He does not have strong ties held to culture.
social and Physical characteristics influencing healthcare decisions:
Poverty, discrimination, healthy food, social exclusion or isolation.
SPIRITUALITY (5 pts)
spiritual and Religious needs:
Believes in blessings. Before any operation or surgery there must be a holy communion.
SELF-CONCEPT (5 pts)
View of self-worth:
He is worth to the society and believes in himself. Ambitious and outstanding.
He aims at establishing his own restaurant. Venture in business and become more successful in life. He also aims at having a full medical cover.
REVIEW OF SYSTEMS (20 pts)
hair Skin, nails:
Skin lesions, changes in hair texture, nails change in color and brittleness.
neck, Head and related lymphatics:
Severe headache, dizziness, swollen neck.
Change in vision, blurred vision.
Ears, mouth , throat and nose:
Sore throats, bleeding gums, in the ears otorrhea.
Emphysema, chest pains, noisy breathing.
Breasts and axillae:
Retrosternal pain, dyspnea on exertion, hypertension.
Swelling of legs, discoloration of hand or feet.
Abdominal pain, pyrosis, nausea and vomiting.
Dysuria, polyuria does not have any history on kidney diseases.
Penile discharge, lumps and hernia.
Stiffness in joints, muscle pains and afternoons back pains.
Sensory function-the patient has never experienced memory disorders.
Motor function- he has experienced weaknesses for the last one week and fainted once.
Barnett,K., Mercer, S. W., Norbury, M., Watt, G., Wyke, S., & Guthrie, B.(2012). Epidemiology of multimorbidity and implications for healthcare, research, and medical education: a cross-sectional study. TheLancet,380(9836),37-43.
Basham,K., Byers, D. S., Heller, N. R., Hertz, M., Kumaria, S., Mattei, L.,… & Shilkret, C. J. (2016). Insideout and outside in: Psychodynamic clinical theory and psychopathologyin contemporary multicultural contexts.Rowman & Littlefield.
Duraiswamy,J., Ibegbu, C. C., Masopust, D., Miller, J. D., Araki, K., Doho, G.H., … & Pulendran, B. (2011). Phenotype, function, and geneexpression profiles of programmed death-1hi CD8 T cells in healthyhuman adults. TheJournal of Immunology,186(7),4200-4212.
Jarvis,C. (2016). PhysicalExamination and Health Assessment–.Elsevier Health Sciences.
Notesin chapter four, documentation of health history records.
Milestone 1: Health History Form Rev. 10/29/14jm