The primary objective of this paper is to present subjective data about the patient, which is vital in the judgment and diagnosis of an individual’s health status (Jarvis, 2019). The paper will provide a complete picture of an individual’s health records, both past, and present. The health history paper provides students with an opportunity to develop skills in collecting subjective data from the patient for the effective conceptualization of patient health, her previous health status, habits, and lifestyle. The assignment provides students with an opportunity to develop interviewing, documenting, and analyzing skills, which are essential in the profession.
Biographical Data
The patient is a 32-year old Caucasian female with an Italian ethnic origin. The patient, who was born in Canada and practices as a doctor, uses English as her primary language. Therefore, there was no need for an interpreter during the interview.
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Source and Reliability
The patient was the sole source of information. She cooperative and seemed reliable throughout the interview.
Reason for Seeking Care
The patient reported experiencing a “throbbing headache” for the last four days.
History of Present Illness
The interviewed revealed that the patient did not have any medical history associated with her current illness. However, the patient experienced a headache two weeks ago before it resurfaced again and remained consistent for the past four days. The headache manifested itself as a pulsing sensation that comes and goes quickly. The patient did not provide a specific location in the head where she is experiencing the pain, and the quality or the quantity of the headache. She has not undergone any diagnostic testing but has attempted to remedy her condition with multivitamins, turmeric, and magnesium and calcium, all of which she takes once a day. These treatments have not been effective in relieving the headache.
Review of Systems
The patient denies any outstanding general health conditions. The patient denies any history of headache, meaning her current condition surfaced two weeks ago and then resurfaced four days ago. Her ears, eyes, nose, and sinuses are in normal condition. She denies experiencing any other symptoms associated with her current condition.
Health Promotion . The employs a good diet and exercise to ensure that she remains healthy at the moment and in the future.
Past Medical History
Childhood Illnesses
The patient denies suffering from any childhood illnesses. The patient did not suffer from measles, mumps, rubella, chickenpox, or pertussis. Also, she did not experience any form of sequela in the later years of her childhood.
Serious or Chronic Adult Illnesses
The patient is currently not seeing a medical doctor for other problems. The patient denies suffering from any chronic illness as an adult.
Trauma, Accident, or Injuries
The patient suffered a left tibia and fibula fracture. She denies experiencing any auto accident, penetrating wounds, burns, or any form of head injury.
Hospitalization
The patient denies any hospitalization in the past. She states that she delivered all her children at home.
Operations
The patient denies undergoing any operation in the past.
Obstetric History
The patient has had three pregnancies, all of which reached full term. The patient has experienced zero number of preterm pregnancies, and zero numbers of incomplete pregnancies. The first pregnancy lasted nine months, with labor lasting for seventeen hours. She gave birth to a healthy male infant weighing 9 lbs. 6 oz. The virginal delivery was successful without any complications. The second delivery also lasted nine months, with the labor lasting six hours, which ended with her bearing a healthy female infant that weighed 8 lbs. 2 oz. The virginal delivery did not raise any complication. The patient’s last delivery lasted nine months, with a four-hour labor period on the delivery date. The patient made a virginal delivery of a 6 lbs. 6 oz male infant. There were no complications during birth.
Psychiatric History
The interview does not record any history of mental health problems. The patient has normal psychosocial conditions.
Immunization
The patient was immunized for DTaP, Influenza, and TB in April 2020, October 2019, and September 2019, respectively. She does not, however, have the knowledge of dates for other immunizations, including measle-mumps-rubella, Hib, IPV, Varicella, Hepatitis, Pneumonia, and Rotavirus.
Last Examination Date
According to the patient, her last examination date was in April 2020, with the results showing that she is healthy. The patient did not undergo any diagnostic testing.
Allergies
The patient claims to be allergic to iodine. Iodine intake by the patient causes hives.
| Medication Name | Start Date | Dose | Route | Frequency | Purpose of the Medication |
| Multi-vitamins | The patient does not recall | The patient does not recall | PO | QD | To treat migraines |
| Turmeric | The patient does not recall | The patient does not recall | PO | QD | To treat headache |
| Magnesium + Calcium | The patient does not recall | The patient does not recall | PO | QD | The patient did not specify |
Family History
The patient’s parents, both mother and father, are alive and healthy. However, while her great grandparents (paternal) were healthy, the great grandparents from the maternal side of her family, particularly her great grandmother, had a thyroid disorder. The patient also has a sister who is suffering from obesity and is pre-diabetic. The patient has three children, all of whom are healthy. Her family line has not recorded any form of cancer, asthma, alcoholism, mental illness, stroke, arthritis, stroke, heart failure, or high blood pressure.
Personal and Social History
Marital Status/ Significant Others/ Interpersonal Relationship
The patient is a single mother of three children. She is the head of the household. Her primary support system is her mother.
Environmental/Living Conditions
The patient lives in a serene neighborhood in a single-family home with her three children. She notes that she gets along well with her neighbors. Also, her house has adequate heat and utilities. The patient commutes using her personal car as the primary mode of transportation.
Domestic Violence
The patient notes that she feels safe at home. She denies being exposed to any form of domestic violence or elder abuse.
Education/ Employment/ Economics
The patient has a medical degree and practices a doctor who specializes in family practice. The patient is financially stable and fully satisfied with her education and feels accomplished in her profession. Her financial capability can service her lifestyle. Following the coronavirus outbreak, the patient has been forced to wear protective gear while at work to avoid any risk of contracting the virus.
Significant Life Event
The patient recently started working with potential COVID-19 patients and thus putting herself at risk of contracting the virus.
Personal Habits
The patient denies the use of any drugs, including tobacco, alcohol, and other street drugs.
Nutrition, Sleep, and Exercise Pattern
Nutrition . The patient practices a good diet. She cooks her own food. She does not take any caffeine during the day.
Sleep . The patient takes a four-hour uninterrupted sleep during the night. In the event she cannot sleep, she runs to help her sleep.
Exercise . The patient runs four miles every day. She has set aside one hour every day for exercise.
Spiritual Assessment
The patient considers herself a religious person. She is a Christian who attends church every Thursday and Sunday. She partakes in community services through the church.
Cultural/Ethnic Background
The patient was born in Canada and identifies as Caucasian. She is of an Italian ethnic origin.
Review of Systems
General Health
The patient denies any outstanding general health problems.
Head and Neck
See the “History of Present Illness” section
Health promotion : No recorded health promotion activities
Eyes
See the “History of Present Illness” section
Health promotion : No recorded health promotion activities
Ears
See the “History of Present Illness” section
Health promotion : No recorded health promotion activities
Noses and Sinuses
See the “History of Present Illness” section
Health promotion : No recorded health promotion activities
Mouth and Throat
The patient’s mouth and throat are in normal condition.
Health promotion : No recorded health promotion activities
Breasts
The patient’s breasts are in normal condition. She denies experiencing pain in the breast.
Health promotion : No recorded health promotion activities
Respiratory
The patient’s respiratory system is in its normal healthy condition.
Health promotion : No recorded health promotion activities
Cardiovascular
The patient has a healthy cardiovascular system. She denies any problems, including chest pain, dyspnea, orthopnea, or palpitation, associated with the cardiovascular system.
Health promotion : No recorded health promotion activities
Gastrointestinal
The patient’s gastrointestinal system is in its normal health condition.
Health promotion : No recorded health promotion activities
Genitourinary
The patient denies any problem with her genitourinary system.
Health promotion : No recorded health promotion activities
Reproductive History
The patient has a normal reproductive history.
Health promotion : No recorded health promotion activities
Musculoskeletal
The patient does not have any health problems associated with her musculoskeletal.
Neurological
The patient denies a history of any neurological health problem.
Psychiatric
In recent months, the patient has been working in an environment that increases her chances of contracting COVID-19. The uncertainty of whether she will be safe at her workplace has been stressful for her.
Endocrine
The patient denies any health problems with her endocrine system.
Hematologic/Lymphatic
The patient denies having any health problems in the lymphatic system.
Health History Summary and Health Problem List
The patient’s headache affects her ability to conduct the daily activities that are required of her. She has not identified a specific cause of her headache. Although the patients claim to enjoy her current state of health, social, and career life, the recent rise in the exposure to potentially coronavirus patients has been stressful.
Aside from the headache, the patient does not have any serious health problems. She should, however, be diagnosed to determine the impact of stress on her mental health. According to Jensen (2018), tension-type headache is the most frequent chronic headache experienced by adults. The tension-type headache is caused by stress and overfatigue. The common symptom of this kind of headache is a pain that feels like being pressed or tightened up. The recent changes in her working environment, which might potentially bring her into a contract with covid-19 patients, could be the primary trigger. In addition, the patient only haves a four-hour sleep per day. Due to the lack of assistance with ADL and her demanding profession, the patient could be overworking herself and having inadequate rest.
| Actual Problem | Potential Problem |
| Headaches | Stress and overfatigue |
According to the health history report, the patient practices good diet and exercise habits, with no indulgence in drugs. The primary remedy for her condition should include increasing her sleeping hours, taking advantage of her support system, that is, taking to her mother about her work conditions, or stepping away from the problem altogether ( Miedziun et al., 2015 ). The patient should attend psychiatric sessions to address her stress.
Nursing Process
The patient experiences headache as a result of stress and overfatigue.
| Patient Goal/Outcome | Interventions | Rationale w/Reference for Interventions | Evaluation of Each Goal/Intervention |
| Reduce the patient’s headache to zero in the pain scale within a week. | Reduce the exposer to the triggers of stress, such as the work environment. Increase the amount of sleep hours Attend sessions with a psychiatrist to discuss the issue. | Reduce the psychological tension through the reduction of stress triggers. The patient will be more relaxed knowing she is not exposed to COVID-19 Increase the time of rest to count the effect of overfatigue Develop a support system that will help the patient in dealing with her issues. | Inquire about any improvements in her health conditions. |
References
Jarvis, C. (2019). Physical Examination and Health Assessment E-Book . Elsevier Health Sciences.
Jensen, R. H. (2018). Tension‐Type Headache–The Normal and Most Prevalent Headache. Headache: The Journal of Head and Face Pain , 58 (2), 339-345.
Miedziun, P., & Czabała, J. C. (2015). Stress management techniques. Archives of Psychiatry and Psychotherapy , 4 , 23-30.
