HEALTH ASSESSMENT RUA PAPERE

2

NR302 Required Health History Assessment – 100 points

Student Name:

1. Biographical Data

Name: Osamudiamen Imuentiyan Address: 2242 CHICAGO, IL

Phone: 773-*****4 Gender: MALE

Birth Date: 04/19/1992 Birthplace: NIGERIA

Age: 29 Marital Status: SINGLE

Occupation: STYLIST Religion: CHRISTIANITY

Race/Ethnic origin: AFRICAN AMERICAN Employer: SELF EMPLOYED

Source and Reliability: Information obtained from the patient; Subjective data collected, the most reliable information that can be obtained

Reason for seeking care: Patient sought care to aid in the Health History Assessment assignment

Present Health or History of Present Illness (HPI): The patient is currently 29 years old, presenting with no current illness. The patient verbalizes that he believes he is in good health

Perception of Own Health: To the patient, he is in good health. The patient states that he goes to the gym regularly, (2-3 times/week) and tries to eat healthily but enjoys fast food. The patient also admits to smoking occasionally but claims that it aids in his anxiety and depression

Past Health:

Childhood illness: Patient denies any childhood illnesses

Serious/Chronic illness: Patient denies any serious/chronic illnesses

Accident/Injuries: Patient reports having suffered from a lesion on the left lateral calf from a piece of glass while taking out the garbage

Hospitalizations: Patient reports being hospitalized for depression and anxiety

Operations: Patient denies any operations performed

Obstetric History: N/A G: 0 T: 0 P: 0 A: 0 L: 0

The course of pregnancy: N/A

Immunizations: Patient reports vaccinations for pertussis, MMR, HepA, HepB, Tetanus, Diphtheria, ProQuad, Polio, and Influenza

Last examination date: Patient said he could not recall but it has been a little over 1 year to date

Allergies: Patient denies any known allergies (NKA/NKDA)

Reaction: N/A Any treatment: N/A

Current Medications: Patient reports taking Venlafaxine and Clonazepam

Family History

Heart Disease: Present in paternal grandmother, states that brother has a heart murmur

Stroke- None to the patient’s knowledge

Sickle cell: None to the patient’s knowledge

Diabetes: Father has Type II diabetes

Blood Disorder: Sister has iron-deficient anemia

Breast/Ovarian Cancer: Patient states that he thinks that his paternal great grandmother passed away from breast cancer; ultimately unsure; Patient denies knowing of any cancer in the family

Cancer (other) – Lung Cancer: Paternal grandfather passed away from lung cancer; skin Cancer – Father had the skin removed from the nose that presented with melanomas

Allergies- Mother allergic to pollen, damp, and dust (patient states mother developed allergies after being pregnant), Maternal grandmother allergic to pollen, Maternal grandfather allergic to cats (pet dander)

Arthritis: Patient states that his mother presented with arthritis

General Overall Health State:

Height Weight BMI

5ft 7inches. 65. 22.4

Skin: Patient denies history of rash, eczema, psoriasis, hives, lesion, and so on

Hair: Patient denies any history of recent hair loss, change in texture and brittleness

Nails: Patient denies a history of change in nail's texture, shape, and color that suggest any infection

Head: The patient denies a history of unusually frequent or severe headache, injury, dizziness (syncope), or vertigo.

Eyes: The patient denies a history of vision impairment or has a history of eye pain rather, redness or swelling, watering or discharge, glaucoma, or cataracts. However, patients claimed that there is a history of cataracts and astigmatism in his family (mother had cataracts and astigmatism)

Ears: Patient denies a history of earaches, infections, discharge, and its characteristics, he also denies having tinnitus or vertigo in the past

Nose and Sinuses: The patient agreed to a history of being allergic to cold and that he often comes up with flu-like symptoms, such as sinus pain, severe cold, nasal obstruction, and sometimes nosebleeds during the winter season.

Mouth and Throat: The patient denies frequent sore throat, having a toothache, and mouth lesion. The patient denies dysphagia. The patient denies tonsillectomy, the patient denies alteration in taste. The patient agrees to have bleeding gum during the fall and winter season

Breast: The patient denies any tenderness in the breast, patient denies the presence of any lumps, patient denies any sign of nipple discharges, patient denies rashes, patient reports no history of breast disease or any form of surgical procedure on the breast

Respiratory System: The patient denies any history of respiratory diseases such as asthma, emphysema, bronchitis, TB, chest pain with breathing, noisy breathing, shortness of breath. The patient agrees to have a cough during the fall and winter season. Patient denies any release of sputum, Patient denies hemoptysis, the patient also denies any known exposure to toxins or excessive pollution, 'Except for living in the fine city of Chicago" When asked how much activity predisposes the patient to shortness of breath, the patient stated he works out so often, only a vigorous physical activity would cause him shortness of breath.

Cardiovascular System: The patient denies a history of cardiac diseases such as chest pain, palpitation, hypertension, coronary heart disease, and anemia. The patient also denies tightness/fullness in the chest, the patient denies dyspnea on exertion. The patient denies paroxysmal nocturnal dyspnea, the patient denies cyanosis, the patient denies any edema, the patient denies orthopnea, the patient denies nocturia. The patient denies any history of a heart murmur. Patient denies anemia

Peripheral Vascular System: The patient denies a sense of coldness, numbness, and tingling, swelling of legs, varicose veins, or complications that may arise from it, discoloration in hands or feet, intermittent claudication, thrombophlebitis, ulcers.

Gastrointestinal System: Patient states he has a very huge appetite as a result of his active lifestyle. Patient report up to 1to 3 bowel movement daily; moderately soft stools present. The patient denies any noticeably recent changes in stool constituency (black tarry stool or melena). The patient denies any unusual flatulence. The patient reported that he is lactose intolerant. The patient denies ingestion. The patient agrees to be nauseated sometimes but denies pain in association with eating. The patient denies a history of abdominal diseases such as liver or gallbladder, ulcer, jaundice, appendicitis, colitis, and rectal condition such as hemorrhoids and fistula.

Urinary System: Patient states frequency of urination is about 1-4 times daily, patient states nocturia to be rare, patient denies dysuria, polyuria, or oliguria. The patient denies urinary urgency, the patient denies straining. The patient denies incontinence, the patient state no history of urinary tract infections, renal diseases, patient denies having pain in the flank, groin, suprapubic region, or lower back.

Genital System: The patient denies any abnormal discharge, the patient denies any knowledge of contracting sexually transmitted diseases, the patient denies any scrotal or testicular pain, the patient denies any genital ulcers. Patient denies any erectile dysfunction

Sexual Health: Patient reports that he is single but uses condoms regularly, patient denies any knowledge of contact with a partner with any STIs

Musculoskeletal System: The patient denies a history of arthritis/gout, the patient denies the presence of any deformity, patient denies any limitation of motion, patient denies any pain, stiffness, or inflamed joints, patient denies any noise associated with joint motion. The patient report muscle pain associated with high levels of exercise "Often after my rigorous and strenuous physical activities" the Patient denies any gait problems/problems with coordinated activities. The patient denies any cramps, the patient denies weakness in muscles, the patient denies any history of back pain or disk disease. Patient denies stiffness in back or limitation in back motion,

Neurologic System: The patient denies any history of seizure or neurological disorders. The patient denies a history of stroke, fainting, or blackouts, patient denies any tremor, patient denies coordination problems, patient denies any weakness in motor function, paralysis, numbness/tingling associated with sensory function, patient confirms having unproved nervousness and patient confirmed it all started a few years ago, stating "It's a fair part of my anxiety" I am learning to manage it through meditation" Patient confirms having mood swing occasionally. The patient confirms depression and a history of mental health including anxiety disorder and denies having hallucinations.

Hematologic System: The patient denies excessive bruising, the patient denies lymph node swelling, the patient states no abnormal bleeding tendency of skin/mucous membranes, the patient denies exposure to toxic agents/radiation. Patient denies any history of blood transfusion

Endocrine System: Patient denies a history of thyroid disease, patient denies history of diabetes symptoms (such as polyuria, polydipsia, or polyphagia), patient denies change in skin pigmentation or texture, patient denies any intolerance to heat and cold, patient denies diaphoresis, patient denies unevenly hair distribution, Patient confirms nervousness, patient denies tremors or any hormonal imbalances that require therapy.

Developmental considerations: patient denies having developmental disorders/abnormalities. Patient states, "My anxiety used to make school difficult, and my medications make me feel drowsy at times"

Cultural considerations: The patient refers to himself as a "Typical African Man" embodying many cultures. Patient states he prefers local African dish and delicacies

Psychosocial considerations: Patient states that anxiety and depression have made it difficult to socialize sometimes, but that he is generally ongoing

Collaborative resources that could be recommended for any teaching/learning needs the client may have (Consider the client’s age as well as any cultural, lifespan, or psychosocial concerns. Think about Community, Family, Groups, and/or Health Care System resources)

Health promotion techniques that will promote emotional/mental health- since the patient states he often has anxiety and loves being alone.

Health promotion for constant screening and checkups

Health promotion for eyes: make sure of yearly vision check-ups and eyes are revaluated.

Health promotion for lifestyle changes related to smoking and diet

Community events would be a great way to utilize resources to achieve the patient's health promotion goals. Communities can hold health functions or free testing for certain health concerns like blood pressure, diabetic checks, and physical examinations. The patient could attend therapy sessions held by the community collaborating with local nurses and health professionals.

REFLECTION – 40 points

My patient and I had a spectacular interactive session outside the church premises after Sunday service. The interactive session with my patient was quite detailed and it highly important to inform the patient beforehand, that this physical assessment is going to be very detailed and will not perform it when the patient is distracted. The interview was kind of challenging because it took me a long time to convince the patient to be as free as possible when expressing himself. The interview was successful as the patient became super relax and free when questions about the review of systems were asked, as the patient gave clear and concise responses in this capacity, which may not have been the case in a real-life scenario. One of the reasons I believed the interview was successful is because I utilized therapeutic communication tools which entail, maintaining eye contact, actively listening to the patient, focusing, summarizing, paraphrasing, the use of open and close-ended questions as at when necessary and whatnot. I also made sure to any barriers to communication, however, I couldn't completely eradicate it from the patient's angle, as friends and family came in and intercepted the exercise on a few occasions. I was able to overcome by asking a couple of questions where the patient had to adopt the data and judiciously have a rethink regarding answers given., free from distraction, and duress. Subsequently, if given another opportunity to interview a patient, a quite and a more secluded environment would be highly beneficial or better. The unpredictable contest was having the patient answer questions like a non-medical practitioner that kind of amazed me since the client was a healthcare practitioner I thought otherwise. I wish I was more detailed when asking "OLD CARTS" about each constructive item on the review of the system, however, this information is subjective to every single point the patient can remember. The fact that the patient is a close family friend that I already have established a relationship with, creating a rapport wasn't necessary. The basic tip for collecting data is getting your patient to trust and have confidence in you, that will prompt him/her to give accurate responses to your question, the other tip is that the patient being interviewed mustn't be hurried or subjected to undue pressure in the course of the interview process. Subsequently, my next approach will be interviewing someone that is not familiar with me in other for me to understand clearly how to build a nurse to patient relationship.