Health History Assessment

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.

HEALTH HISTORY ASSESSMENT 3
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.