Health History for Health Assessment

NSG306 Health Assessment: Health History on Mr. Ricky Ricardo Jean Bors-Koefoed & Sarah Wright Baptist College of Health Sciences Health History Biographical Data Date: 05-23-2010 Name: Ricky Ricardo Gender: Male Race/Ethnicity: Hispanic Marital Status: Married Date of Birth: XX/XX/XX Occupation: Medical Device Representative Address: XXX XXXX XXXXXXXXXXXXXXX Phone Number: (XXX) XXX-XXXX Contact Person (relationship to patient): Lucille Ball/wife (XXX) XXX-XXXX Reason for Seeking Healthcare: “Providing a Health History for Health Assessment”

History of Present Illness: Patient does not have a present illness. He is only seeking care for the purpose of providing a health history for the interviewer’s assignment. Obtaining the history of the presenting illness of a patient is important in determining if the illness is a one-time acute condition, or one of a more chronic nature. If the patient has experienced the same illness or symptoms in the past, it can be helpful to know how the condition was treated and how successful the treatment was, so a current course of therapy can be prescribed effectively.

In the case of Mr. Ricardo, because he does not have an illness at the present time, he would not have a history of an illness to provide. Current Health Status: Medications (prescribed/over-the-counter): The patient is prescribed Adderral for ADHD. Patient takes 30mg/2x a day. Last dose taken was May 18, 2010. Patient also takes Benadryl when needed. Medications are important to document because they can sometimes be the cause of what is wrong. Prescribed drugs and over-the-counter drugs can interact with each other and have negative consequences.

It is also important to consider dosage of each medication because the dose itself might need to be adjusted because it is causing problems. For this patient, this information can be significant because Adderral has various side-effects that can affect other aspects of the patients’ life, such as depression of his appetite, or hindering his normal sleeping patterns. Upon further investigation, Mr. Ricardo did mention “occasional problems falling asleep”, which could be the result of the side effects from his medication. Allergies (meds, food, environmental, medical products): The patient is allergic to cats and has seasonal allergies.

When the patient comes in contact with a cat, he breaks out in hives and has a runny nose. His seasonal allergies cause a runny nose, sneezing, and itchy, watery eyes. History of allergies may explain current problems or give insight as to what could be adding to the problem. It can also prevent life-threatening situations. For example, if the patient was allergic to penicillin they could have a severe allergic reaction that could possibly result in death. This is why it is important to know what the patient is and is not allergic to.

While the patient interviewed did not have any severe allergies to medications or food, his seasonal allergies are important to note, should he ever present with symptoms commonly associated with his allergies, so he can be properly diagnosed. Past Health History: Childhood Illnesses: As a child, the patient had Influenza, chickenpox, throat infections, and Osteomyelitis. While the patient was unable to remember the exact dates he had experienced the flu as a child, he had the chickenpox for approximately one week in the summer of 1985, and was inflicted with osteomyelitis in October of 1984.

He remembers several bouts with strep throat throughout his childhood, though he is unsure of the quantity or timings of the disease. Mr. Ricardo hasn’t had any complications in later years due to throat infections. Childhood illnesses can have a direct influence on a person’s current health condition. A history of one illness as child might explain later illnesses in adulthood. For example, childhood chickenpox, as this patient has experienced, will explain shingles in an adult.

The patient’s infection which caused his osteomyelitis, suggests that the patient is now colonized with Staphlococcus Aureus bacteria, which will hopefully remain a part of his normal flora without causing any further infections. Should he experience another infection similar to one typically caused by Staph, understanding that he has had a Staph infection in the past can help physicians make an accurate diagnosis quickly and treat the infection accordingly. Hospitalizations: The patient was hospitalized in 1984 for two weeks for Osteomyelitis.

He had to undergo surgery to remove the infection in the proximal portion of his left tibia.. Hospitalizations in the past can give insight to a current or pre-existing condition. The specifics of a hospitalization make it easier to receive the medical records if necessary. It is also important to record any psychological hospitalizations because they can also give explanation to current health issues. With just the one hospitalization in his health history, the Mr. Ricardo is unlikely to have any residual problems resulting from his stay. Immunizations: The patient is up-to-date on all immunizations.

According to the patient’s health records from the Pennsylvania Department of Health, he received the last of five Diphtheria-Tetanus-Pertussis on November 3, 1980. He also received just a Tetnus-Diptheria vaccination on October 23, 1990. He had the final dose of the three Oral Polio immunization on January 30, 1979. He had both his Rubella and his Mumps vaccines on September 18, 1980, and he received his Measles vaccine on August 2, 1980. He had a tuberculosis immunization on August 29, 1991, and had his last TB test 2-01-2010, which was read to be negative. He received the Hepatitis B series between September and December of 1996.

Because the patient currently works in hospital settings, he also had a titer done for all of the above diseases as further certification that he was indeed vaccinated on February 1, 2010. Current problems can be explained by a patient’s immunization history, or by their lack of immunizations. It is important to have them updated if patient hasn’t received all or if they are just needing a tetanus shot. They help prevent diseases that are harmful if not life threatening. The patient is up to date on all common immunizations, with the exception of the varicella-zoster boosters, which was not routinely given when the patient was younger. Since e has had chickenpox in the past, he is considered to have the necessary immunity to the disease. Last Examination: The patient’s last physical was Dec. 2007. Patient had elevated blood pressure (hypertension) due to stress. It was resolved on the follow-up visit on Feb. 2008. The patient’s last vision exam was Aug. 1997. The patient had 20/20 vision according to his last visit. His last dental exam was Feb. 2010. The patient has perfect teeth, and no cavities. Yearly examinations are very important. It keeps the person having the exam and the physician up-to-date with their health status. They also detect early onset of certain diseases.

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While this patient has been remarkably healthy in the past, the elevated blood pressure signified that he may not effectively handle stress, and could lead to a problem later down the road. Since it has been well over the recommended year between vision screenings, it is advisable that Mr. Ricardo visit an ophthalmologist to make sure his vision has not changed, and that everything is healthy with his eyes. The patient should also schedule another physical examination with his general practitioner to assess his overall health, including his physical, mental, and psychosocial well-being, as well as to monitor his medications.

Family History Spouse: His wife is 30 and is in good health. Son: His son is 2 and is in good health. Daughter: His daughter is 1 mo old and is in good health. Mother: His mother is 60 and is in good health. Father: His father is 60 and has Type 2 diabetes, obese, and has hypertension. Maternal Grandmother: His great grandmother is deceased. She would be 83 and she had Alzheimer’s disease. Maternal Grandfather: His great grandfather is deceased. He would be 71 and he had heart disease. Paternal Grandmother: His great grandmother is 84 and has breast cancer.

She has been in remission since 2004. Paternal Grandfather: His great grandfather is 85 and has COPD and has hypertension. He had Bi-pass surgery in 2009. Maternal Aunts: He as two aunts and they are 63 and 55. They are both in good health. Maternal Uncle: His uncle is 65 and has chronic back pain from an injury. Paternal Aunt: His aunt is 63 and is in good health. Paternal Uncle: His uncle is 55 and is in good health. Sister: His sister is 30 and struggles with her weight. Brother: His brother is 26 and struggle with addiction, depression, and personality disorder.

It is very important to retrieve family history so that genetic diseases can be spotted. Also, there are many hereditary conditions that might skip a generation, but give insight into a particular condition. Because there are several of the patient’s family members that struggle with hypertension, and obesity, particularly central obesity that can predispose him to Type II diabetes, understanding these genetic tendencies can help him make wise lifestyle choices to lessen his chances of being afflicted by the same conditions. These lifestyle choices can include altering his diet and exercising more consistently.

The presence of Alzheimer’s Disease in his genogram is also significant, and he should become aware of the symptoms of the disease and look out for any early signs of onset as he continues to age. Developmental Evaluation At 32, Mr. Ricardo is in Erickson’s developmental stage of early adulthood, where the focus is on resolving the conflict of intimacy vs. isolation. Because Mr. Ricardo married at an early age (age 23), and has developed a very positive, intimate relationship with his wife, he struggles very little with the conflict between achieving intimacy over isolation.

He is a very outgoing individual, and not only has maintained many of his friends from childhood and college despite moving across the country, he has also cultivated a well established group of friends here in Memphis as well. He is very involved in the community, volunteering as a docent at the zoo, and is involved with Inner city programs of Memphis through his church. He has been happily married for 9 years and is actively involved in the parenting role, enjoying loving relationships with both his son and daughter.

He is working in the industry of his choice, and has been highly successful throughout the past eight years as a medical device representative. While Mr. Ricardo does outwardly appear to have fully resolved the conflicts of early adulthood, he does feel he sometimes is “chasing something better with his career, constantly not being satisfied with his company or compensation. ” This suggests he still has some issues he needs to address before moving into the next stage of his life. Understanding where the client is in Erickson’s stages of development is important in understanding hat inner conflicts a patient might be dealing with that could be affecting their physical, mental, or psychosocial well-being. This can also help guide a practitioner into what further questions should be asked of the patient in evaluating their health. A patient that may be experiencing conflicts typical of other stages of development that are not typical for their age could be exhibiting signs of a developmental delay. Mr. Ricardo is experiencing very normal conflicts for his age-appropriate developmental stage of early adulthood and is showing positive signs of working towards resolving any conflicts of intimacy vs. isolation.

Psychosocial Profile Family/ Social Relationships: As the head of household, the patient is happily married with 2 children. He maintains a very close relationship with his immediate and extended family members, although he has had some what combative relationship with his father and brother in the past, particularly during childhood, and during the time in which he has lived with them. Although high-strung, he has a very consistent and loving relationship with his wife and children. The patient is very social and keeps in close contact with both new and old friends. Family and social relationships are important in a person’s life.

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It’s best to try to maintain a happy, healthy relationship with your family and friends. Having a dysfunctional relationship with family can put strain on a person’s life. Understanding his temperament, it is important to consistently check in with the patient to make sure his relationships are continuing to be positive. Diet/ Nutrition: The patient has maintained a fairly high metabolism throughout his life, being able to eat basically whatever he wants despite minimal exercise. His appetite varies with life circumstances, and he tends to eat more during stress-free periods.

He typically eats three meals a day, his biggest one being at night, often after 8 or 9pm, as he is usually not hungry until then. He does not diet, but does crave sweets. He also consumes on average of 2 alcoholic drinks a day, although more on the weekends. A person’s nutritional intake can affect their health. Meeting a person’s dietary needs is very important. It can health problems if a person is under or over nourished. While Mr. Ricardo is currently at a healthy weight for his age and stature, it will be important to continue to monitor his diet as he ages and metabolism slows so that he continues to onsume a healthy diet and avoid excess caloric intake. Also, with Type II diabetes in his family history in combination with his penchant for sweets, his blood sugar should be routinely monitored to avoid developing the condition himself. Functional Ability: Mr. Ricardo is able to perform all self-care activities independently. Being able to perform functional abilities independently is important, especially for adults with physical and mental disabilities and older adults. If a person is not able to perform these independently, they will have to either have someone to move-in and help them, or move into an assisted-living facility.

In Mr. Ricardo’s case, he still maintains all functional abilities and is not dependant on anyone for his daily activities. Mental Health: Mr. Ricardo has suffered from ADHD and dyslexia since childhood. He also dealt with a short bout of depression and anxiety after the birth of his first child, during a time of extreme stress at work. The patient, while usually a happy person, is often easy to anger and is highly irritable during times of exhaustion and high stress. He does not handle stress well, often relying on chemical interventions such as alcohol, marijuana, and/or prescription drugs.

A person’s method of dealing with stress can show a lot about their health status. The coping methods might be damaging to the person and possibly make their problems worse. Getting advice about coping with stress is important so that person doesn’t turn to recreational drugs to cope. The patient has exhibited signs of struggling to cope with stress effectively. If not addressed, perhaps by psychotherapy, this could start to have severe adverse effects his general health as well as on his mental state and personal relationships. Personal Habits: Mr. Ricardo doesn’t use tobacco products.

He consumes 2-3 alcoholic beverages a day, and smokes marijuana during times of high stress or on occasion recreational use. He has also taken pain medication and Xanax recreationally in the past. Some personal habits can have negative effects on health. Smoking and illegal drug use will cause problems in a person. It is necessary to document the personal habits so that if there is association between a habit and a condition, it will present itself. Because the patient has a history of recreational drug use, it is important to address these behaviors now before they start to have a negative impact on his health.

It is also important to make sure his use is not habitual or frequent, and stress to the patient that illicit use of these drugs can have very serious consequences. Health promotion: Mr. Ricardo walks with his family daily, and lifts weights at the gym twice a week for 20 min. He does self-examination daily in the shower. Bram brushes his teeth twice a day, and his last screening was Dec. 2007. Studies show that regular exercise and activity increases a person’s health. Self-examinations are very important to practice. By doing these examinations you can detect any abnormalities in those areas and have it checked.

Practicing health promotion increases a person’s well-being. In general, Mr. Ricardo practices health promotion through diet, exercise, and excellent personal hygiene as well as by being aware of his body and any changes that may be occurring. Environment (including living and work environment): Mr. Ricardo lives in a healthy environment. He lives in an upper middle-class suburban house in Germantown, TN with his family and two dogs. As a medical device rep, he spends much of his time in a car and in hospitals, where he is routinely participates in surgeries with physicians.

He drives and average of 500 miles a week and spends between 1-2 nights a week out of town. When out of town, he stays in well-kept hotels, and eats his meals at restaurants. The environment that a person lives and works in has a great impact on their health. A person living in a dangerous or dirty environment can be an indicator of health problems. Animals that are not properly cared for can also affect a person’s health due to factors such as sanitary concerns, and/or parasites that can be passed from animal to person.

People working for companies that make them travel frequently can cause a lot of stress and tension on a person’s body. Traveling can also expose a person to a variety of people, which increases the amount of illnesses they come in contact with. Because the patient does travel frequently as well as work in a healthcare setting, he does come in contact with far more germs than the majority of the population, however, he practices excellent hygiene and infection control procedures such as frequent hand washing, thus rarely gets sick.

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While traveling, he does often eat in restaurants, making it somewhat harder to maintain a healthy diet. The patient needs to be more aware of his diet while out of town and make healthy selections when ordering meals. Spending frequent nights in different locations can also affect sleeping patterns, and the patient should try and limit drastic changes to his nighttime routine to help minimize sleep disturbances. Despite having two large dogs, both Mr. Ricardo and his wife maintain a sanitary living environment, limiting any accumulation of dirt or dag hair brought into the house by the animals.

They are also very diligent about keeping their pets up-to-date on all of their shots through semi-annual visits to a local veterinarian. Review of symptoms General symptoms: The patient has been having problems sleeping, due to having to take Adderral for work and from being out of town for an extended period of time. Since returning home on Friday, he has not had any problems with sleep. A review of symptoms helps give an overall picture of a clients’ physical health.

By asking specific questions relating to each of the body systems, a practitioner can sometimes uncover symptoms a patient has forgotten about or not known to include without investigation. This can help the medical professional know where to target their physical exam or treatment therapies more specifically, as well as help in determining the patient’s own perception of pain, health, and illness. Besides the sleeping issues relating to his medication, the review of his symptoms did not uncover anything too surprising or requiring further investigation at this time.

Integumentary System: Skin: He has no skin problems. Hair: His hair isn’t thinning out and doesn’t color his hair. Nails: He doesn’t have any problems with his nails. Eyes: He has 20/20 vision and uses sunglasses only for driving. Ears: He has no hearing or ear problems. Nose, Nasopharynx, Sinuses: No history of sinus infection, difficulty breathing through nose, or nose bleeds. Bram suffers from seasonal allergies due to pollen. Mouth/Oropharynx: He has a sore throat when weather changes. He brushes his teeth twice a day and has never had a cavity.

Respiratory System: He has no breathing problems. Cardiovascular System: He has no cardiovascular or heart problems. Gastrointestinal Disease: He has no GI problems, has regular bowel movements. He occasionally experiences heartburn, usually after eating rich foods late in the evening. Urinary System: He has no problems with urination. Musculoskeletal System: Never had a broken or fractured bone. Neurologic System: No neurological problems. Reproductive System: He has no lesions, discharge, pain or masses. Sexual Activity: Mr.

Ricardo is currently involved in a sexual relationship with his wife of 9 years. He has had one sexual partner in the last 3 months. Since he is married, there is no need to protect himself from STD’s. His wife maintains the responsibility for providing birth control for the couple. She was taking an oral contraceptive, but has recently been implanted with an IUD. There aren’t any problems in their sex life. Illness can affect a person’s sexuality, both physically and emotionally. If the client is in a relationship where sexuality is a problem, it can often lead to stress and depression.

Dangerous sex patterns can be an indication of illness or a precursor to contracting an illness. The patient interviewed appears to have an active and healthy sex life that poses no current problems to his overall health. Summary of Findings: The patient is 32 years old and is in good condition. He is currently in the stage of “early adulthood” and experiences some stress. He is very happy with his marriage and his life is headed in the right direction. He has a good relationship with his family despite some issues with his father in the past.

He stays in close contact with all of his friends. He is involved with his children and his community. He also attends Bible study on a regular basis. Mr. Ricardo seems to have his life in order, but I would recommend working on methods of stress reduction. The patient has admittedly turned to alcohol and recreational drugs to cope with his stress in the past. It could be beneficial for him to seek psychotherapy to help him understand his stress better and learn new, healthier ways to combat life stressors.

I would also recommend another physical and vision examinations, as both examinations are outdated. The older a person gets the more important it is to keep up with your health status. Frequent examinations can help uncover early signs of problems not readily detected by the patient until the conditions progresses to a more advanced stage. The summary of findings is an important tool to help give a brief, overall picture of a patient’s health, and see what nursing recommendations have been made for the patient.

On follow-up visits, practitioners can then assess whether or not a patient has complied with the recommendations for care, and how that compliance has impacted his or her health. For Mr. Ricardo, the nursing recommendations are to both have a more recent physical and vision examination performed, as well as to seek help in dealing with stress. Assuming the patient complies with these recommendations, his current health and stress management techniques can be re-assessed on future exams.