NR 304 Health Assessment 2

6

Health History Information Interview

Chamberlain University College of Nursing

NR302 Health Assessment 1

October 1, 2021

Demographic Information

Jeremy is a 52 year-old white male who reported complaints of abdominal pains. The patient complains of having abdominal pains that has been persistent for 3 days. He reports that the pain was acute at the onset with a scale of 9/10 but reduced to 5/10. The abdominal pains are general and there is no specific part of the stomach that is affected. Now he is able to eat, except that he nauseates after meals and also experiences diarrhea. There is no specific timing when the pains are severe, but it is a generalized pain. The patient reports that there are no exacerbating or relieving factors. The patient does not seem to have any growth abnormality and seems okay in all aspects. He also appears to be in good shape for his age and a BMI of 20.7.

Past Medical History

There is no record of pharmacological history, and no known immunizations were recorded. The patient also does not have any history of surgeries or illnesses related to the stomach. The patient did not indicate his occupation or hobbies. He denies any tobacco usage, but admits to being an occasional drunk. He is married with three children who are two boys and a girl. He has no drug allergies and is currently on Metformin 1000mg, Amlodipine 5 mg, Lantus 10 units qhs, and Lisinopril 10mg, medications.

Family History

The patient does not have a history of any form of cancer. The father had diabetes mellitus type 2 and hypertension. The mother suffered hyperlipidemia and gastroesophageal disease. The patient also never married and is not seeing anybody at the moment. Despite being a Catholic family, they never had any issues with seeking medical care. The family never had any religious or cultural restrictions that would hinder their pursuit of health. None of the family members also had a history of mental illness.

Cultural Considerations

The patient does not have any cultural issues that may influence his decision to seek medical attention. He is a devout Christian but does not let his religion interfere with his medical decisions.

Developmental Considerations

The patient has no developmental issues. His height is okay, and he has does not seem to be experiencing challenges pertaining to aging. He exhibits good morbidity and does not require any form of aid in going about his ADL.

Psychosocial Considerations

The patient is in his right state of mind and does not seem disoriented. His speech is okay and does not have any psychosocial issues. He has not suffered any significant form of stress or depression over the last seven years.

Collaborative Resources

The patient seems to be aware of his dieting requirements. However, he admits that he may require more knowledge from a dietitian as he never seeks information from any. He also admits that he does not handle the cooking at home, hence, only eats whatever his wife cooks.

Review of Systems

The patient exhibited a slight rise in the body temperature (99.7°F); RR 16; BP 160/86; P 92; Weight 248lbs; and HT 5’10”. There is no record of visual loss, blurred vision, or double vision recorded. There are also no yellow sclerae. No hearing loss, no sneezing or nasal blockage, and no sore throat or runny nose. The skin had no lesions, no urticaria, and no rash or itching. Cardiovascular examinations returned no murmurs in the heart, no chest pain, and no chest discomfort. No palpitations or edema. The respiratory examinations also revealed a symmetrical chest wall, no shortness of breath, and no cough or sputum. The patient also had a soft abdomen, and hyperactive bowel sounds. The patient experienced nausea after meals, and diarrhea. Genitourinary exams revealed no burning sensations on urination. The patient also indicated that he did not experience dizziness, headache, syncope, ataxia, paralysis, tingling in the extremities or numbness. However, there was a considerable change in bowel movement. There were no enlarged nodes or history of splenectomy, back, muscle, and stiffness or joint pains, anemia, bruising or bleeding, and no history of anxiety or depression. The endocrinologic report returned no reports of sweating, cold or heat intolerance. Also, there was no polydipsia or polyuria recorded. The patient appeared dehydrated. The skin was intact and the patient had lost some weight. His last medical examination was four months ago, and a full body exam was conducted on him. All his results came out fine.

Reflection

The interview occurred at a local health facility, and the patient chose the place because it was his day at the clinic. Admittedly, it was rather mind-boggling to approach him with the suggestion of conducting the interview. However, upon establishing the desired connection, I gained an insightful experience into the patient’s life experiences. Initially, I thought of conducting the interview in a relatively different place, but the patient suggested that I accompany him on his clinical visit. It was nice interacting with the caregivers, and I got a chance to learn a couple extra things from them too. We closed on a good note, and the patient was willing to grant me another interview in the future.

References

Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment (8th ed.). Saunders.