Health History Assessment

Read about the health history assessment of a 42-year-old female patient who visited the emergency department for her regular weekly physical examination. The article covers demographics, perception of health, past medical history, family medical history, vital signs, review of systems, developmental considerations, cultural considerations, psychosocial considerations, collaborative resources, and reflection. Subject: Health, Course Code: N/A, Document Type: Assignment, Assignment Type: Case Study

Running head: HEALTH HISTORY ASSESSMENT 1
Health History Assessment
Student Name
Institutional Affiliation

HEALTH HISTORY ASSESSMENT 2
Health History Assessment
Demographics
Mrs. Z N is a 42-year-old female patient who visited the emergency department today for
her regular weekly physical examination. She is a patient on follow-up in the hospital and comes
in every week for checkups. She is a Hispanic American who is a cashier at Citibank in the US.
Perception of Health
Mrs. Z has a positive attitude toward her health and healthcare providers. She says she
can be able to reduce her weight and reduce alcohol consumption. She believes in the importance
of lifestyle changes, healthy diet, and regular hospital checkups in improving her quality of life.
She also considers the benefits of effective communication and interaction with the healthcare
providers, as she shows respect and confidentiality in them. Generally, she says she is in good
health.
Past Medical History
Mrs. Z was diagnosed with childhood asthma at a tender age. She suffered severe asthma
attacks where she was admitted severally in the hospital for acute management. The patient was
admitted, nebulized with Salbutamol, put on oxygen therapy, and prophylactic antibiotics. The
mother received healthcare education on the chronic nature of asthma and the management at
home. Currently, she uses Symbicort inhaler. She suffered from severe pneumonia at the age of
4, which complicated to bacteremia and pleural effusion. The patient had a thoracostomy tube
inserted to drain the effusion. The patient stayed in the HDU for three weeks, where she received
specialized care to complete recovery.

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Mrs. Z had a fracture to the wrist due to a fall when she was eight years. She reports to
have had several infections from bronchitis till the age of 13 wit persistent coughs, but results of
gene expert were negative. She receives annual gynecologic exams, and her family planning
method is the use of IUCD. Her previous cervical screening test was negative. She was
diagnosed with Hypertension at 35 years, which she has under control to date. She is currently on
Hydrochlorothiazide, atorvastatin, Nifedipine and Symbicort inhaler.
Family Medical History
Mrs. Z is the second born in a family of three. All siblings are alive; the sister diagnosed
with cervical cancer two years ago and is currently on management. Her father died in twenty
thirteen after battling a diagnosis of Hypertension and cerebrovascular accident. Her mother is
alive and is a known diabetic on medication. Maternal grandfather died at 75 from a heart attack,
and the grandmother died at 90 from cervical cancer. Her paternal grandfather died at 80 from an
asthma attack and Crohn's disease, and the grandmother died at 92 due to complications of
Hypertension. She is married to one husband who is alive and healthy with three living children.
Vital Signs
Temperature- 37.2⁰C
Respiration Rate- 18 breathes/min
Pulse- 80 beats/min
BP- 138/88 mmHg
The vital signs are within normal ranges in comparison to normal reference values.

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Review of Systems
General appearance
The patient is well groomed and appears to have gained weight compared to the last
clinical visit. She weighs 75kgs, the height of 160cm hence a BMI of 29, indicating she is
overweight (Jarvis, 2016). She reports that due to the nature of her work, she rarely walks or
exercises. She gets tired after minimal activity and gets palpitations. She is in a happy mood,
oriented, and generally looks healthy.
Head and neck
No reported headaches or head injuries. She has no previous scars or growths. Eyes exam
is standard with pupils’ equal, round and reactive to light; PERRLA (Saathoff, 2018). No ear
discharges or hearing problems reported. There are no sores on the mouth or lips. The neck veins
are not distended, and the neck is soft. On palpation, the thyroid is not enlarged, and the trachea
is central.
Pulmonary
The patient has chronic asthma. She occasionally experiences cough, shortness of breath,
and wheezing during exertion or exposure to pollen. There is bilateral chest expansion with
normal breath sounds on auscultation.
Cardiovascular
The patient was diagnosed with Hypertension 5 years ago. Bp- 138/88, which is normal
according to reference ranges. No complaints of chest pains. Capillary refill is <2secs and has no

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cyanosis. She has slight edema on lower extremities with no ulcers. On auscultation, no murmurs
or bruits heard.
Gastrointestinal
The patient reports no chronic issues in the GIT. On observation, the abdomen is not
distended; normal bowel sounds auscultated with tympanic, and dull sounds felt on percussion
(Rastogi et al., 2019). There were no masses or ascites detected on palpation. No history of
change in bowel movements or chronic pain reported.
Genitourinary
Normal female external genitalia present. No incontinence, hematuria, abnormal, or
discharge reported. The patient has no history of past gynecological or urinary tract infection.
Neurological
The patient has no history of suffering from any chronic neurological condition. No
history of headaches or loss of consciousness. All cranial nerve tests are intact. Mrs. Z has never
had a seizure or feeling of numbness of any part of the body.
Musculoskeletal
The patient has adequate muscle tone and strength. No muscle wasting has a whole range
of motion activity. No complaints of cuff or back pains. No evidence of joint swelling or
tenderness. All bones are intact with no fractures or dislocation.

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Developmental Considerations
Mrs. Z reports to have undergone normal developmental stages in her life, and she reports
having typical milestones including neck support at three months, sitting at six months, walking
and talking by one year. She reports having no difficulties in learning till college level and
presents a brilliant academic record. She reports being a social person who quickly makes friends
and partners. She states having attained secondary sexual characteristics at the age of 13. She
also says having sustained friendships and relationships with family and friends.
Cultural Considerations
Mrs. Z believes that mentioning the probability of poor prognosis is likely to make it
occur; hence, she requires positive sentiments concerning her health. She prefers eye contact as
she believes it is a sign of respect and concern. She reports no cultural opinion regarding her
condition hence believes in the medical causes. Mrs. Zack is ready to make any diet adjustments
to promote her health since her culture does not forbid her from consumption of any food.
Psychosocial Considerations
Mrs. Z reports to be of sound mind, and she is a mother who takes care of her children by
working at the Citibank, which she takes seriously. She says that as a normal human being, she
faces daily stresses and can handle them with her spouse. She has never had any psychological
issue that necessitated psychotherapy. Relaxation techniques such as yoga and meditation are
among the methods of managing stress. She reports to have a positive view of life and is eager to
improve her health to be there for her husband and children.

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Collaborative Resources
Patient and the family members show great collaboration with the healthcare providers.
Mrs. Z has never missed any hospital appointment and is always escorted by a family member.
They all ensure that all investigations required have been performed in time after being
requested. She is adequately adherent to her medications and has been able to control her
Hypertension.
Reflection
In my reflection on my client assessment, the client was examined at the emergency
department at midday. I applied therapeutic communication techniques where a section was
selected, adequate lighting provided and screened to ensure patient privacy and conducive
environment. The proper introduction was done, and communication initiated. I was able to state
my names and explain to the patient that today, I will be handling the physical exam. An open
approach was used whereby I used open-ended questions which enabled the client to be
comfortable hence cooperate. I also enquired if the patient was comfortable with the language I
used in communication. During the discussion, I continually asked for clarity and maintained eye
contact with my client.
In comparison with what I have learned, my interaction from the client was good. I
applied most of the techniques learned in class and the skills acquired in prior clinical
experience. From my interaction with the client, client history was obtained in detail, including
relevant familial history. Frequent interruptions and noise were among the communication
barriers experienced. I overcame them by switching off the television in the room and placed a
sign outside the selected area to inform other people that the city was busy hence avoid

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interruptions. In the future, before the beginning of an interview, I will ensure to inform the staff
to avoid interruptions. No unanticipated challenges were experienced, and I wish I had obtained
information on her eating habits to help me advise her on a healthy diet to reduce her weight. I
future, I would have gained more experience and confidence. I will apply non-verbal cues during
the interview to improve the efficiency of the interview

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References
Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Canada: Elsevier.
Rastogi, V., Singh, D., Tekiner, H., Ye, F., Mazza, J. J., & Yale, S. H. (2019). Abdominal
Physical Signs and Medical Eponyms: Part II. Percussion and Auscultation, 1924–
1980. Clinical medicine & research, CMR-2018, 5(2), 228-241.
Saathoff, A. (2018). The nurse's guide to bedside eye exams. Nursing made Incredibly
Easy, 16(5), 19-22.