Health History Assessment Essay

Health History Assessment and Physical Assessment 2

Health History Assessment and Physical Assessment

I conducted a health assessment on a 70 year’s old male patient from California who was

suffering from hypertension. The patient is currently taking diuretics medication which cause

increase urination. The medication also causes his sodium and fluids levels to drop thus lowering

patient’s blood pressure so it’s imperative to balance and monitor vital sign. The patient stated

that he was moderately satisfied with the care received in the facility. The patient is a smoker and

stated his concern of experiencing vision issues and heart failure, which prompted immediate

care for this patient.

Before being admitted to the hospital, patient stated that he was experiencing chest pain

which was not ending nor was it increasing in exertion. He did not experience nausea, vomiting,

dizziness or unconsciousness. He took some pain killers with no relief but managed to sleep in

the morning. After beginning his daily activities, the pain increased and was then rushed to the

hospital. He underwent some test that clarified that he was suffering from hypertension. When I

reviewed patient past medical records, it showed that he has condition at early age and minor

surgery. I reviewed the patient's cardiovascular, eyes, nose, throat, respiratory system, and his

immune system. Patient immunization was also put into consideration when I reviewed his past

medical record as this will be helpful planning for his care.

Thirty years ago, the patient developed a diffuse rash after he was injected with penicillin

which he was allergic to, but it was not known. Some of his past health operations includes:

chest pains in 1990 and minor surgery on his left arm. He has a medical case of pneumonia at an

early age, which did not take long to heal. The patient was raised by his stepmother since his

mother passed away 72 years ago from heart failure. His father passed on 68 years ago after

committing suicide in his house. His wife died 10 years ago after struggling with tuberculosis for

Health History Assessment and Physical Assessment 3

a long period of time. He has six children; two are deceased after both suffered from

hypertension. He has 20 grandchildren and 10 great-grandchildren. His family have history of

hypertension but no known history of tuberculosis.

The patient’s physical assessment findings were that he had an elevated blood pressure of

125/80 which shows that it was high, but it is controllable. I also found that he had a unique heart

sound which was as a result of an enlarged heart. The patient had a swollen neck vein which was

probably caused by heart failure. He also had some abnormalities in the blood vessels behind the

eyes. He has no clinical cardiovascular disease or signs of hypertension-related target- organ

damage. The patient had narrowed kidney arteries and endocrine disorders. The patient had no

respiratory problems, but his lungs sounded as if it was congested. His peripheral pulses were

present and strong, and his thorax was under the normal shape.

Through health teaching topics, students can acquire knowledge, skills and positive

attitude about health. From these teaching, students can learn about physical, mental emotional

and mental health. This enables students to enhance and maintain their health in preventing

diseases and minimize risky habits (Don, 2000). Through this teaching, student acquire positive

changes and behaviors that reduce the risk of the student being around alcohol, tobacco, and

other drugs. Through this teaching, the community becomes aware of how to prevent chronic

diseases as well as how to maintain healthy nutrition and prevent obesity (Vadurro, 2018).

Through the finding in the scholarly articles, there has been great awareness about chronic

diseases and how they can be prevented and managed by integrating such as nutrition and how to

deal with stress. The findings also advance the understanding of how the mind and body

strategies impact health and well-being. The findings mainly focus on the treatment of diseases,

Health History Assessment and Physical Assessment 4

this has helped in finding treatment for diseases and the productiveness of pharmacologic

strategies in treating and controlling the illnesses (Green LW. Et al. 1980)

The interrelationship of psychological developmental, cultural and psychosocial

consideration impacts a person's experiences and definition of health and illnesses. This

relationship guides the day to day lifestyle of people. It determines if people in given community

access to health care and their responses to disease pain and disabilities. Through the integration

of individual strength and collaborative resources, the proposed health teaching will be well

appreciated in the community since through these strengths they will improve the population-

level health outcome by supporting the proposed health teaching which may lead to a sustainable

environmental transition in different parts of the community which are associated with health.

The patient was not willing to share the information with me as he considered it as a

distraction. To comfort patient, I began by explaining to him the importance of the interview. I

explained to him the information was required for learning purpose which helped in convincing

him that the interview was not aimed at interfering with his privacy since the information will

not be shared by any third party. I explained to him the benefits of speaking about his health

conditions and with the information shared, it will be easier to come up with a better medical

plan that will help a medical professional care for his needs. I explained to him that if he shared

his health information, I will be able to explain to him the living habits that he was expected to

adapt based on his condition. When conducting my next physical examination, I will ensure that

I implement the four techniques which involves inspections, palpation, percussion, and

auscultation.

Health History Assessment and Physical Assessment 5

References:

Don Nutbeam. (2000, September) Health literacy as a public health goal: a challenge for

contemporary health education and communication strategies into the 21st

century, Health Promotion International, 15(3), Pp. 259–267. Retrieved from

https://doi.org/10.1093/heapro/15.3.259

Vadurro Marcy. (2018, February 8). The Importance of Health Education. Retrieved from

https://www.snhu.edu/about-us/newsroom/2018/02/importance-of-health-education

Green LW. Et al. (1980). Health education planning: a diagnostic approach. Retrieved from

https://www.popline.org/node/499039