Assignment on Health History

Health History
Gender Male/Female
Female
Age 50
Current Medical History
What current medical conditions do
you have?
I am 50 years old male and I have many problems
related to health. The major health issue I am having
is arthritis. It causes pain, restriction in moving and
inflammation. Because of this my joints are weak. I
have also hypertension and due to this my blood
pressure in arteries is constantly elevated. Also I have
asthma since childhood. This causes problem in
breathing sometimes.
Past Medical/Surgical History
What is you past medical/surgical
history?
Medical History
I have operated once for minor heart
Surgical History
There was laser therapy for kidney
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attack. This resulted in weakness
and breathing problem.
stone before 9 years.
Medications
What medications do you take?
List medications and dosages (where
possible)
For arithritis person is taking the following
medications -
 Analgesics, such as hydrocodone (Vicodin) or
acetamonophen (Tylenol) for getting relieve
from pain.
 Nonsteroidal anti-inflammatory drugs
(NSAIDs), such as ibuprofen (Advil) and
salicylates as this helps in help controlling
pain and inflammation (Briggs, Rethman, &
Lopez, (2018). Salicylates help in thinning
blood.
 Menthol or capsaicin creams for blocking the
transmission of pain signals from the joints.
 Immunosuppressants like prednisone or
cortisone for reducing inflammation.
Also hypertension the patient takes medicines like
Bumetanide (Bumex) and Chlorthalidone (Hygroton)
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Do you live alone/with
someone?
Alone/with someone
with someone
Are you able to care for yourself?
Do you need help with showering?
Do you need help with toileting?
Do you need help with dressing?
Yes/No Yes
Yes/No No
Yes/No No
Yes/No No
Do you have a vision impairment?
Do you wear glasses?
What type of glasses are they?
Yes/No Yes
Yes/No
Do you have a hearing impairment?
Do you wear a hearing aid?
Which ear do you wear them in?
Yes/No No
Yes/No No
Right ear/Left ear/both
Do you wear dentures?
Are they upper/bottom dentures?
Yes/No No
Upper/bottom/both
Do you drink alcohol?
How often do you drink?
How many drinks do you have each
day?
Yes/No Yes
Drink is consumed once in a month
Do you smoke?
How many cigarettes do you smoke
a day?
Yes/No yes
3 – 4
Do you follow a special diet?
What is the special diet?
Yes/No Yes
Balanced diet is consumed which includes
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What is your height?
What is your weight?
pulses, roughage and carbohydrates. The
main focus is on iron rich food items.
5 feet 8 inches
80 Kg
Do you have any mobility issues?
Do you use a mobility aid?
What mobility aid do you use?
Do you do any exercise?
Yes/No Yes
Yes/No No
Yes. Yoga is done every morning
Do you have any wounds?
Where are they?
Yes/No No
1) Nursing assessment tool used – Result - Laboratory tests are included in treatment
of arthritis. Fluids form body is taken for for
analysing and these fluids includes joint fluid, blood
and urine. Imaging is used is an assessment used in
arthritis patient. The imaging test helps in detecting
various problems with joints Byrd, May, & Marsden,
(2017). Some of these are X-rays, computerised
tomography (CT) and Magnetic resonance imaging
(MRI).
X -rays – In this type of treatment, low level of
radiation is used for visualising bones. X-ray shows
cartilage bone, bone spurs and bone damage. X-ray is
used for tracking progression of arthritis in patient.
2) Nursing assessment tool used
–
Result -
Computerised tomography (CT) – The CT scanners
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