Health Assessment

Partner Health History Paper

Stratford University

NSG 330

February 22, 2022

Partner Health History

Health History

Biographic Data

Name: J.C

Address: 784 Greenwood Street, Laurel, OH 29103

Date of Birth: 02/09/1971

Birthplace: Dallas, TX

Marital Status: Single

Occupation: Lawyer

Race/Ethnicity: Black/ American

Health History

Reason for seeking care: Chest pain

History of Present Illness: This is the first Hospital admission for this 52-year-old lawyer with a history of hypertension. Mr. J.C noted the abrupt onset of a dull aching pain in the retrosternal area while delivering a summation in court. The pain radiated into his left arm and upper jaw, was associated with a feeling of queasiness, and sweating and lasted 10 minutes. He sat down and let his associate finish the summation and the pain went away spontaneously after 5 minutes. Later that afternoon, while playing squash, he had the onset of similar but more severe aching pain, in the same distribution, associated with queasiness, sweating and weakness. An ambulance brought him to Greenville’s Emergency Department. This pain lasted about 30 minutes and was relieved when he was given NTG. He says he has “borderline cholesterol.” His father died of a myocardial infarction at age 54; one brother aged 47 has heart disease. He has never smoked. He denied any shortness of breath, palpitations, previous similar pain, diabetes or known cardiac disease.

Past Medical History:

Mild asthma as child-now completely resolved

Chickenpox – age 7

Eczema—still has mild and infrequent

Hypertension, first noted at age 47- does not know if it is controlled with meds

Past Surgical History:

Tonsillectomy – age 5

Appendectomy – age 18

Vasectomy – age 42

Injuries:

Fractured tibia while skiing – age 38

Immunizations:

Normal childhood immunizations

Last tetanus shot – age 38 when had the tibial fracture

Complete Covid vaccine

Medications:

Norvasc 5 milligrams daily po

Multivitamin over the counter

Allergies:

Not known.

Health Maintenance Screening

Last eye exam 1 year ago- reportedly normal

Hemoccult check for blood in stool – 6 mos. ago –negative per pt

Prostate exam – 6 mos. ago- normal per pt

Family History

Father – died at age 54 -MI, was hypertensive

Mother – 76, alive and well 

2 siblings: Brother - 47 – S/P MI

Sister – 49 healthy

3 children: Son – 28, healthy

Son – 25- asthma

Daughter – 22 healthy

Social History

Attended University of Pennsylvania and Villanova Law School. Works as partner in law firm. His job is extremely stressful. He is currently separated from his wife, and lives with his girlfriend. He is only sexually active with her and has no problems. Does not use condoms. They have a turtle. He has three children with whom he has a close relationship and feels he has a good support system. ETOH: a glass of wine with dinner. Denies drug use. Does not exercise regularly except for playing occasional squash. No blood transfusions. No chemical exposure or recent foreign travel. No history of abuse.

Review of Systems:

General: gained 20 pounds gradually over past yrs. no fever, chills, sweats, fatigue.

Skin: no rashes, photosensitivity.

Head: “sinus headache”, no history of head injury

Eyes: wears reading glasses, no history of eye pain, red or pink eye, decreased tearing or eye discharge. Saw ophthalmologist last year.

Ears: denies difficulty hearing, ear infection, discharge or dizziness

Nose: recurrent seasonal rhinitis (tree pollen in the spring), no epistaxis. Has had recurrent sinusitis, ENT doc tells him he has polyps

Mouth and Throat: recurrent cold sores, no recent sore throat Respiratory: denies shortness of breath, cough, hemoptysis, positive TB test or exposure. No recent wheezing; no orthopnea, PND.

Cardiac: see HPI

Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or bleeding per rectum. Takes Metamucil for irregularity at times.

Genito-urinary: No hematuria, dysuria or urinary hesitancy. No penile discharge.

Endocrine: no change in skin or hair, no polyuria or polydipsia, no hoarseness, dysphagia, intolerance to temperatures

Vascular: No claudication or ulcers. No varicose veins.

Musculoskeletal: Tennis elbow right arm, intermittently, uses a splint when he plays squash. No gout, arthritis, back pain

Neurological: no history seizure, no sensory loss, no motor weakness, no migraines, no paresthesia Psychiatric: seeing a therapist regarding the separation from his wife

Functional Assessment :

Self-Esteem/ Self Concept: Graduated high school and have professional degree in law.

Financial Status: Sufficient, having a good financial status.  

Value/ Belief System: Buddhist. 

Self-Care Behaviors: Have excessively good family time with girlfriend and his Children.

Activity/ Exercise ADL’s: Active lifestyle. She has a very strict timetable in both social and professional life. Exercise regularly before going to duty and have continuous working activity.

Sleep and Rest: Sleep deprivation. Approximately 7 hours of sleep in a day.  

Nutrition and Elimination: He was a food lover in past and loves sweets. He has a very tough duty and mostly eats outside.  Girlfriend prepares food for him occasionally. He reports that his loss of appetite is quite crucial for last two months.  

Interpersonal Relationships and Resources: She works for her family and enjoys a strong bond with all her siblings, husband, son and her in-laws. 

Coping and Stress Management: He is suffering from anxiety and takes sleeping pills for stress release. No addictive habits.  

Personal Habits: Morning meditation: 20 minutes of meditation every morning before the day activities, non-smoker, non-alcoholic. JC reported having a cup of hot cocoa and brushing his teeth every night before going to bed 

Environment and Hazards: J.C lives in a double story house in Dallas Texas. He is a tenant and lives on the upper story. High risk of fall and imbalance while climbing the stairs is expected. He reports that her neighbors are quite friendly.

Intimate Partner Violence: Feels safe at home, no abuse reported. No report of mental, psychological, or otherwise physically hurt by partner. Partner has never forced him into having sex. No report of threat from anyone. He enjoys excellent family relationships with all his family members.

Occupational Health: He works at a law firm. Occupational hazards like depression and workaholism chances are quite evident. 

Perception of Own Health: He was a bit worried about his current weight and not exercising often. He viewed himself as not physically fit and that might not be good for his overall health.

Future Goals: He has decided to follow a complete diet plan and prescribed medicines. Also, to be more active by exercising 30 minutes every day.