Health History Assessment
Interviewee: J. H. (male)
Age: 37 years old
• Demographic data – Client lives in Georgia; warm or mild to a cold climate.
• Perception of health – Identify exercise is beneficial for his current health which he is willing to exercise regularly on a daily basis.
• Past medical history – He had appendectomy when he was 10.
• Family medical history – diseases in his family include diabetes, stomach cancer, colon cancer, and hypercholesterolemia.
• Review of systems –
GENERAL HEALTH
• A Little fatigue, no fever, no weakness, no sweats, no recent weight change.
SKIN
• No change in color, no rash, no lesions, no pruritus, no history of skin disease. The bruise on Lt. Index fingernail; injured during work (automobile mechanic). Hair: No loss; has some gray hair. Nails: no change.
HEAD
• Mild headaches sometimes; had concussion 10 years ago while snowboarding; mild memory loss; MRI was normal, no syncope, no dizziness.
EYES, VISION
• No history of eye diseases. No current eye pain, inflammation, or dryness. Wears eyeglass; farsightedness.
EARS, NOSE, MOUTH, THROAT
• No history of ear disease, hearing loss or difficulty. No pain; no vertigo, discharge, or tinnitus.
• No nasal discharge now; usually one to two colds per year; no sinus pain, nasal obstruction, or nasal bleeding. Has seasonal allergy; a mild runny nose and obstruction.
• Has canker sore, No toothache, No bleeding gums, No hoarseness, No dysphagia, or No sore throat. Never had tonsillitis.
NECK
• No pain, No swollen glands, No lumps, or No limitation of motion.
HEART, CARDIOVASCULAR
• No chest pain, fatigue, palpitation, orthopnea, dyspnea on exertion, nocturia. No history of heart disease.
GASTROINTESTINAL
• Little change in appetite; especially in summer. Having little indigestion problem, but on and off. No heartburn. No pain and mass in the abdomen. No nausea/vomiting. No history of gastrointestinal disease. Bowel movement 2 to 3/day, soft, brown; no rectal bleeding or pain.
MUSCULOSKELETAL
• No pain in joints, swelling, stiffness, or limitation of motion. No history of the disease. Mild muscle pain or weakness due to work.
PERIPHERAL VASCULAR
• No swelling in legs, pain, numbness or tingling. No history of the disease.
GENITOURINARY
• No symptoms and history of disease and symptoms; dysuria, frequency, urgency, nocturia, hesitancy, or straining. No pain in the flank, groin.
RESPIRATORY
• No history of respiratory disease; no chest pain with breathing; no wheezing or shortness of breath. Colds come with asthmatic symptoms sometimes; treated with prescribed steroid medicine. Non-smoker; father and older brother are a cigarette smoker. Works in the well-ventilated workplace, but occasionally there is exhaust gas and dust from the automobile.
NEUROLOGIC
• No history of seizure or fainting. No numbness. No mood change, depression, memory problem, or nervousness.
HEMATOLOGIC
• No bleeding problems on the skin.
ENDOCRINE
• Father with diabetes. No increase in hunger, thirst, or urination.
• Developmental considerations – he was raised with love from parents and grandmother. He has positive perception and mind which lead him to peaceful living.
• Cultural considerations – he was religiously raised as Catholic, but now he does not go to church.
• Psychosocial considerations – He likes to meet new people and has a conversation. He likes to learn things from other people’s story.
• If you were to perform a physical assessment, which body system would be a top priority for evaluation and why? - I would prefer to evaluate his gastrointestinal system for a top priority since he has a family history of stomach and colon cancers and Diabetes. I will recommend early screenings such as CT and endoscopy.
• List two teaching/learning need priorities for this individual (Consider Age, Psychosocial, Cultural, Lifespan concerns) – Need to watch his diet and organized timely exercise daily basis.
• Collaborative resources (Think Community, Family, Groups, Health Care System) – His wife, church members, and his shop co-workers.
Reflection
Based on learning from class and book, the actual interaction of an experience was different. It required more of my common senses towards this patient and I had to think of different ways to communicate without making the patient feel uncomfortable. I questioned and evaluated well by having more conversation and later on, the patient felt comfortable and described and explained his symptoms and family medical history. The only barrier that I felt was trusting each other when we first start to communicate about this symptom. I noticed he was not open to answering all questions that I asked him in the beginning, but after few conversations, it went well. I’ve tried my best to answer his question and every word that I come out of my mouth was very careful words because I was making sure when I ask a question to him, I didn’t want him to feel discomfort. An interview went well with all of the questions, but he and I were only careful in the beginning, but after several questions mixed with conversations made myself and interviewee comfortable to ask and answer questions. I did not want to obtain any questions and answers while I interview him because it is his medical questions and answers and I believe medical questions or records stay as confidential to protect patient’s privacy. Now I learned while I did this interview, I need to change myself to approach patients by using more warmth words and detailed introduction of myself to make interviewee or patient’s to feel more comfortable.
Reference
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). St. Louis, MO: Elsevier.