Assignment on The Health History
Added on 2021-05-31
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Date ............................................................Interview conducted by ............................Designation ................................................1. Biographical dataName: Robert WalkerAddress: 15 Louis Avenue Brighton 5048Date of birth: 7th November 1930Birthplace: AustraliaAge: 83 GenderMale Marital status: MarriedOccupation: Technical person in a breweryEmployer: Not discussedInterpreter required? NoMedicare number (Not required for the assignment).............................................................Private Heath Fund Details (Not required for the assignment) Not discussed........................Advanced care directive?Details: Not discussed2. History obtained from: The patient himself3. Reason/s for seeking care .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................4. Present health or history of present illness At present, the patient is free from the illnesses like cold and influenza but he is no longer strong enough as he used to be and that he feels tired most of the times. No serious illness in childhood that dragged him to the hospital. In the last year, he was appointed for an abdominal operation due to some bowel obstruction. 5. Past healthGeneral health: General condition is good and suffered from no major illness or health issuesChildhood illnesses: No illness detectedAccidents or injuries: Once fell down from a tree and broke the left arm ...........................................................................................................................................................Source: Jarvis, C & Denmead, E (Australian adapting author) 2012, chapter 7 ‘The health history’, in Student laboratory manual for physical examination and health assessment, Australian and New Zealand edition, Saunders Elsevier, Sydney, pp. 65–73.NURS1004 Part 1 Documentation for Health assessment
Serious or chronic illnesses: No such illness. Once had an abdominal operation due to bowel obstructionHospitalisations: For the operation of abdominal issue due to bowel obstruction and once due to broken leg. Operations: For the operation of abdominal issue due to bowel obstruction and once due to broken leg. Cataract operationObstetric history ............................................................................................................................Gravida ....................... Term ....................... Preterm ...........................(# Pregnancies) (# Term pregnancies) (# Preterm pregnancies)Term / Incomplete .................. Children Living ......................................................................(# Terminations / Miscarriages) Course of pregnancy ..............................................................................................................................................................................................................................................................................(Date delivery, length of pregnancy, length of labour, baby’s weight and sex, vaginal delivery / caesarean section, complications, baby’s condition)ImmunisationsTetanusCurrentSelect Yes................................................................................InfluenzaCurrentSelect Yes................................................................................PneumococcusCurrentSelect Yes................................................................................Other ................................................................................................................................................................................................................................................................................Last GP visit date 20th February 2013..............................................................................................Health ScreeningDentist Once or twice a year.................. Vision Last year (2012) for cataract operation Hearing Earlier this year......................... ECG A number of times..............................CXR Yes............................................ Other ..........................................................Allergies: Allergens and reaction – allergy bracelet applied Select.....................................Drugs / medications No........................................................................................................Food No...............................................................................................................................Latex / other No...................................................................................................................Comments No allergies to any specific thing.....................................................................................................................................................................................................................Infection controlPage 2 of 7
Transmission-based precautions .......................................................................................Notifiable disease ..............................................................................................................6. Family historyHeart disease Not known.................................................................................................................High blood pressure No...................................................................................................................Stroke No.........................................................................................................................................Diabetes No......................................................................................................................................Blood disorders No..........................................................................................................................Breast cancer No..............................................................................................................................Cancer (other) Mother died of lung cancer .....................................................................................Sickle cell No...................................................................................................................................Arthritis Father might have..............................................................................................................Allergies No ...................................................................................................................................Asthma No.......................................................................................................................................Obesity No one was grossly overweighed.......................................................................................Alcoholism No.................................................................................................................................Mental illness No.............................................................................................................................Seizure disorder No.........................................................................................................................Kidney disease No............................................................................................................................Tuberculosis No...............................................................................................................................Other .............................................................................................................................................Review of symptoms, function and risksThere is no such risk or symptoms observed regarding the ill health of Robert. Robert has been doing OK and that he can drive a bike or ride a car. There is no severe health issues identified. The present condition is due to the old age like loss of hearing. 7. General overall health and wellbeingPerception of health ........................................................................................................................Interpersonal relationships / resources ..........................................................................................Education (last level achieved) Bachelor degree in chemical technology from University of Adelaide.........................................................................................................................................Current employment Retired since 1st Jan 1993...................................................................Family role? ......................................................................................................................Support systems? Daughters are very supportive, receives pensions from Government because his wife is blind and gets blind benefit pension...................................................................Values and beliefs / spiritual resources Believes in cultural practices.............................................Page 3 of 7
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