I. Health History Assessment
Patient’s Name: A. C.
The patient is 38 years old married male; lives in Georgia since 1995. The patient is here to control blood sugar and hypertension. Identify controlling blood sugar and hypertension by exercise and diet control is beneficial for his current health and he is willing to do it on a daily basis. Patient currently takes medications such as atenolol for HTN and metformin for DM. doesn’t have any allergies. All vaccinations and immunizations are up to date. Patient’s father had DM, HTN and stomach cancer which he dies from it. Mother has DM and Hyperlipidemia. He was raised with love from parents and mostly grandmother. He has positive mind and perception that lead him to peaceful living. He was raised as Catholic, but now he prefers to stay home during the weekend. He is open-minded like to have a conversation with new people. He is willing to learn things that improve his life. There were no collaborative resources.
The patient complains mild headaches sometimes; had concussion 10 years ago while snowboarding; mild memory loss; MRI was normal, no syncope, no dizziness. No history of eye diseases. No current eye pain, inflammation, or dryness. Wears eyeglass; farsightedness. 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. No hoarseness, No dysphagia, or No sore throat. Never had tonsillitis. No neck pain, No swollen glands, No lumps, or No limitation of motion. 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. No chest pain, fatigue, palpitation, orthopnea, dyspnea on exertion, nocturia. No history of heart disease. No history of seizure or fainting. No numbness. No mood change, depression, memory problem, or nervousness. 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. No pain in joints, swelling, stiffness, or limitation of motion. No history of the disease. Mild muscle pain or weakness due to work. No swelling in legs, pain, numbness or tingling. No history of the disease.
For his diabetes, he has to monitor his blood sugar by exercise and strict diet such as low carbs diet and encouraging a diet rich in fiber. Exercise is beneficial to not only diabetes but also healthy people. It helps people control their weight and decrease the risk of having a certain disease. We can obtain fiber from foods such as broccoli, peas, and berries. According to Ley et al, high fiber diet helps to control blood sugar level (2016). Although I provided good education to the patient, he mentioned that he needs high-calorie food for his work. He also said that he works 12 hours per day for 30 min. lunchtime, and due to his busy schedule most of the time he has fast food for a meal. I encouraged him to change the diet, and he seemed to understand the importance of diet to control his blood sugar.
Because of his young age, it was hard to believe he had diagnosed with hypertension. He sees it affected by a genetic factor such as family history. Like another disease, it is important to control high blood pressure. If it untreated, it can cause serious complications such as cardiovascular disease and renal dysfunction (Koliaki & Katsilambros, 2013). In order for him to control his blood pressure, educating him about maintaining a healthy weight, being active, and eating the right food. The most important one is eating the right food. There is a heart-friendly diet call Dietary approaches to stop hypertension (DASH) diet. The evidence shows that DASH diet which rich in vegetables, fruits, and low-fat dairy products and low in saturated fat (Koliaki & Katsilambros, 2013).
Reflection
Obtaining health information from an unknown person was not easy especially there was not enough time to build a rapport with the patient. Building a rapport is essential to obtain quality health information for the patient. It was somewhat harder to build a rapport with the patient than I expected and I noticed that it requires practice. Although I have been here for almost two decades, there still was a barrier to performing a health history and physical exam. Because I am an Asian and it was male patient, it was uncomfortable to touch others. It was because I have the different cultural background. So, I asked a favor to a patient’s family member to stay in the exam room during the exam. I noticed that practice help a lot. With plenty of practice of head to toe assessment, I can act like the professional nurse who knows what she is doing. But, I also noticed my limitation providing information relates to diabetes and hypertension. When the patient asked some questions about medications that he takes, I couldn’t answer it. But I told him that I do not know and I will look up for him. I believe that I handled it the way professional nurses do. But overall, it was very successful to obtain a health history and conducting a physical examination which makes me more confident. I strongly believe that I can do much better next time.
Reference
Koliaki, C., & Katsilambros, N. (2013). Dietary sodium, potassium, and alcohol: key players in the pathophysiology, prevention, and treatment of human hypertension. Nutrition Reviews, 71(6), 402-411. doi:10.1111/nure.12036
Ley, S. H., Ardisson Korat, A. V., Qi, S., Tobias, D. K., Cuilin, Z., Lu, Q., & ... Hu, F. B. (2016). Contribution of the Nurses' Health Studies to Uncovering Risk Factors for Type 2 Diabetes: Diet, Lifestyle, Biomarkers, and Genetics. American Journal Of Public Health, 106(9), 1624-1630.