Nursing: History & Physical Assignment

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Adult Health History

First and Last Name

Indiana University Southeast

Adult Health History

This documentation is a comprehensive health history of TJ, a 45 year old male who lives

in Indiana. TJ has been married for 25 years. He and his wife have two daughters who are 21

and 22. The oldest daughter has a masters in elementary education and teaches in the Greater

Clark school corporation. She has been married for two years and she and her husband are

expecting their first child in May. The youngest daughter is finishing her senior year of nursing

school at the University of Louisville. TJ denied having any cultural, religious or spiritual values

that would inhibit him from participating in this interview. TJ denies any exposure to domestic

partner violence or sexual abuse. The interview took place in TJ’s living room. The setting was

very nice, quiet, comfortable, and free from distractions.

Present Health/History of Present Problem(s )

TJ reports no present health issues.

.

Past Health

Childhood illnesses

TJ denies having measles, mumps, or rubella (MMR ), and pertussis. He did report

having chicken pox at age six. Many episodes of strep throat (denies knowledge of rheumatic

fever), tonsillectomy at age nine.

Accidents or injuries

Bike wreck in third grade, broken collar bone and pulled growth center from humerous.

Laid in traction for three weeks at hospital. Doctor was not sure if damage to growth plate would

cause long term issues. Arm grew at normal rate and size, no problems.

Serious or chronic illnesses

Denies any history of serious or chronic illnesses.

Hospitalizations

Only hospitalization was in 1979 when shoulder was broken as documented under

“Accidents and injuries”. No long term complications.

Operations

Surgery to repair collar bone and growth center in 1979. No long term complications

Obstetrical history

Does not apply.

Immunizations

Has documented history of the following vaccines: MMR, polio, diphtheria-tetanus-and

pertussis (Dtap), and varicella. Denies having hepatitis A or B, meningococcal vaccine, human

papilloma virus, haemophilus influenza type B, pneumococcal vaccine, and influenza as a child.

Has received influenza vaccine every October for past 20 years. Hepatitis B was administered

February of 1991. The last tetanus immunization was in 2014. The last tuberculosis skin test was

January 13, 2016. TJ advised he will be receiving Dtap before the birth of their first grandchild

in May.

Last examination dates

Has dental checkup twice a year along with oral cancer screening. Last physical was in

2015. Denies hypertension, hyperlipidemia, any occult blood, or any issues. Denies issues with

hearing loss. Has never had an electrocardiogram or chest x-ray. Performs self testicular exam

on the 20th day of each month. This is a male client so there is history of mammogram or pap

smear. Vision was tested in 2015, no issues found.

Allergies

Denies any drug, food, environmental, contact, or latex allergies.

Current medications

Occasionally will take 400 milligrams (mg) of ibuprofen or 650 mg of acetaminophen

for headache (once every couple of months). Denies any other prescribed or street drugs. No

herbal remedies.

Family History

Maternal grandmother died from breast cancer at the age of 70. Maternal grandfather

died from a heart attack at the age 52. Paternal grandmother died in her sleep at the age of 92.

No history of any disease process. Paternal grandfather died in his sleep at the age of 94. No

history of any disease process. Mother is 69 years old and has history of hypertension and supra

ventricular tachycardia. This is controlled with metoprolol and is taken each night before bed.

TJ’s father is 71 years old and has no history of any disease process. There is no family history

of stroke, diabetes, obesity, cancer, arthritis, allergies, alcohol or drug addiction, mental illness,

seizure disorder, kidney disease or tuberculosis. Denies any long term exposure to tobacco

smoke, communicable diseases, or any other environmental exposures.

Review of Systems

General constitution

Advises general health is good. TJ rarely gets a cold, fever, or sore throat.

Skin, hair & nails

Denies any issues with dry or oily skin or hair. States nails are not brittle.

Head, neck

Denies any issues with head or neck.

Eyes, ears, nose, and throat (EENT)

Denies any issues with EENT

Chest/lungs, and breast (for women)

No issues with chest or lungs.

Heart/blood vessels, and peripheral vasculature

No problems with heart/blood or peripheral vascular systems

Gastrointestinal (GI)

No issues with GI system.

Endocrine

Denies any issues with thyroid or diabetes.

Female (menses, pregnancies)

Does not apply.

Genitourinary

Denies any issues.

Musculoskeletal

Denies any issues.

Neurologic

Denies any issues.

Functional, Personal & Social History

Activity/exercise

Employed at Ford Motor Plant four days a week, twelve hours a day. Returns home, has

dinner, may take a walk with spouse. Have a pool they get in every evening during the summer

months. No mobility issues.

Sleep/rest

No difficulty sleeping. Goes to bed at 11:30 p.m. and gets up at 4:30 a.m. Daytime

napping may occur on a Sunday afternoon for an hour or two.

Nutrition

Denies any unintended weight loss or gain. Eats all types of food and includes a variety

of vegetables, fruits, and meat. Denies any food allergies. TJ states he drinks two cups of coffee

each morning and has six to eight glasses of water a day. His treat in the afternoon is one coke.

There are no foods forbidden due to cultural or religious values. He and his wife both participate

in cooking dinner and there is no problem obtaining groceries or preparing them.

Relationships/social support

TJ and his wife enjoy going to church on Sunday mornings. They will have dinner with

all of the siblings the first Sunday of every month. He and his wife have a couple of friends they

attend the high school basketball games with and go out to eat dinner with. They have family

dinner every night, and attempt to have dinner at least two Sundays each month with both

daughters and son-in-law. Thanksgiving is alternated each year. TJ’s sister hosts one year, and

TJ hosts the next year. Christmas Eve is spent with both daughters and son-in-law. Christmas

day is calm with holiday movies. Family is very important to both TJ and his wife. Their faith is

very important to them and TJ said he does not know what he would do if he did not believe in

Jesus Christ.

Stress and coping

TJ states he really has no stress in his life other than awaiting the arrival of their first

grandchild. When the girls were younger and would cause a little chaos, he normally would go

for a walk, pray, and have a beer. If he needs to de-stress in the summer months, he goes for a

swim their pool. He commented he is very thankful his girls did not get in much trouble.

Personal habits

TJ denies any tobacco use or recreational drugs. He has five or six beers a month.

Safety issues

TJ lives in a gated community and feels safe in his home and neighborhood. He

advised he wears his seatbelt every time he is in a car. He uses sunscreen when outside.

Financial concerns

TJ has exceptional healthcare, can afford his medication (tier level), and says all

preventative care is covered at 100% .

Conclusion

TJ stated he could not think of anything of importance that he omitted from our

conversation. He felt he had been very open and forthcoming when answering the questions.

This writer was very appreciative TJ was open and welcoming of the interview.

Self-Evaluation

Open ended question were utilized during this interview. The living room was spacious

and quiet. There were distractions. Clarification and silence were used during the interview.

Silence is an obstacle to get through without squirming and wanting to talk. This writer did not

fall into any of the ten traps of interviewing. The question about sexual assault and domestic

violence was added to the questions for this interview. Griffin & Kross (2002) and The Joint

Commission on Accreditation Healthcare Accreditation (JCAHO) (2010) have encouraged all

nurses to ask the client “Are you now or have you ever been a victim of sexual assault and/or

domestic violence”. JCAHO (2010) suggests this should be done at every level of care (moving

from intensive care unit(ICU) to the floor, from the emergency room to the floor, when there is a

divorce, change of significant partner, or any life event). The client may not disclose the first

time asked but may eventually feel they are in a safe environment to disclose and ask for help.

References

Griffin, M., & Koss, M. (January 31, 2002). Clinical screening and intervention in cases of

partner violence. Online Journal of Issues in Nursing,(7)1. Retrieved from

www.nursing.world.org.Main MenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/

TableofContents/Volume72002/No1Jan2002/ClinicalScreeningandPartnerViolence.aspx

Joint Commission on Accreditation of Healthcare Organizations. (2010). Preventing violence in

the healthcare setting. Retrieved from www.jointcommission.org/assets/1/18/sea_45.pdf

Jarvis, C. (2012). Physical examination and health assessment: Text and physical examination

and health assessment online video series (6th ed.). Philadelphia, PA: Elsevier, Saunders

Wooldridge, M.B., & Shapka, J. (2012). Playing with technology: Mother-toddler interaction

scores lower during play with electronic toys. Journal of Applied Developmental

Psychology, 33(5), 211-218. http://dx.doi.org/10.1016/j.appdev.2012.05.005

INDIANA UNIVERSITY SCHOOL OF NURSING

B344 Comprehensive Health History

Adult Health History Assignment Grading Rubric

Complete Adult Health History
Topics	Exceeds Standard (points)	Meets Standard (points)	Below Standard (points)	Comments
Introductory Paragraph*	5	4	3
Present Health/History of Present Problem(s)*	5	4	3
Past Health*	15	12	10
Family History*	15	12	10
Review of Systems*	15	12	10
Functional, personal and social history*	15	12	10
Conclusion*	5	4	3
Self-Evaluation of Interviewing Techniques
Reflection*	15	12	10
Writing Guidelines
Writing	10	9	8
Total Points

*See assignment description for full discussion of expected content.

Exceeds Standard: Essential content fully and thoroughly developed (A or B work); Meets Standard (C work): Contains essential content; Below Standard: Essential content missing/incomplete (< C work)

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