Clinical Practice Health History Project Report 2022

Running Head: CLINICAL PRACTICE 1

CLINICAL PRACTICE 2
Health History
Gender Male
Age 68
Current Medical History
What current medical conditions do you
have?
foot pain, recent increase in weight, and suboptimal diabetes check
Past Medical/Surgical History
What is you past medical/surgical history?
Medical History
Experienced periods of nocturia due to his
eating habits (huge pasta dishes and Italian
Surgical History
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CLINICAL PRACTICE 3
pastries)
Symptoms indicating hyperglycaemia 2 years
before diagnosis
Patient has a history of type 2 diabetes that
has lasted for five years
Medications
What medications do you take?
List medications and dosages (where possible)
atorvastatin (Lipitor), 10 mg daily
glyburide (Diabeta), 2.5 mg every morning
Do you live 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
Yes
Yes
Yes
Do you have a vision impairment?
Do you wear glasses?
No
No
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CLINICAL PRACTICE 4
What type of glasses are they?
Do you have a hearing impairment?
Do you wear a hearing aid?
Which ear do you wear them in?
No
No
Right ear/Left ear/both
Do you wear dentures?
Are they upper/bottom dentures?
No
Upper/bottom/both
Do you drink alcohol?
How often do you drink?
How many drinks do you have each day?
Yes/
Daily
8 oz. of red wine
Do you smoke?
How many cigarettes do you smoke a day?
No
But used to be a heavy smoker quit 10 years ago
Do you follow a special diet?
What is the special diet?
What is your height?
What is your weight?
No
5 feet 8 inches
243 lbs
Do you have any mobility issues? yes
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CLINICAL PRACTICE 5
Do you use a mobility aid?
What mobility aid do you use?
Do you do any exercise?
No
Golfing once in a while
Do you have any wounds?
Where are they?
No
1) Nursing assessment tool used –
BMI Calculator
Result – 36.9 kg/m2
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CLINICAL PRACTICE 6
2) Nursing assessment tool used – lancet
device
Result – normal glucose level 178 mg/dl
3) Any other nursing assessment tools used Result
Any other information you wish to add in relation to the person you interviewed.
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