Comprehensive Health History
Health History
Biographical data:
No name or initial is required
Age: 50 Marital status: Married
Birth date: 6/08/1971 Number of dependents: 5
Educational level: Master’s Degree in Neurosurgery Gender: Male
Occupation (current or, if retired, past): Chief of Surgery
Ethnicity/nationality: African American
Source of history: The information was provided by the patient himself, which means it is very reliable
Present health history:
Current medical conditions/chronic illnesses:
The patient reports a history of hypertension since 2018 and GERD for an unknown period.
Current medications:
Nifedipine 20mg PO OD
Hydrochlorothiazide 25mg AM OD
Antacid tablets
Medication/food/environmental allergies:
The patient reports an allergy to penicillin
Past health history:
Childhood illnesses:
The patient reports suffering from otitis media and tonsillitis
Denies any history of rubella, asthma, pertussis, chickenpox, and mumps
Hospitalizations/Surgeries
2007- Vasectomy
2015- Dental surgery to remove plaques
The patient reports about four hospitalizations since 2013 due to stress and exhaustion associated with
Accidents/injuries:
The patient reported collapsing in 2018 due to work exhaustion with no significant injuries.
The patient denies any motor vehicle accidents, severe burns, or lacerations.
Major diseases or illnesses:
The patient denies any major childhood illnesses. He is currently suffering from hypertension and GERD.
Immunizations (dates if known):
Tetanus 08/2014 Diphtheria Unknown Pertussis Unknown Mumps Unknown
Rubella Unknown Polio 07/2017 Hepatitis B 08/2021 Influenza 12/2017
Varicella Unknown Other Typhoid fever 08/2017, Yellow fever 08/2013
Recent travel/military services: The patient traveled to Africa in January. He has no history of military service.
Date of last examinations:
Physical examination 08/2020 Vision 08/2020 Dental 08/2020
Family History (Genogram)
Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any major health issues, and, if indicated, cause and age at death. Present as a genogram.
Review of Systems
General health status
The patient reports fatigue and work stress. He, however, denies any pain, night sweats, weight loss, and trouble sleeping.
Integumentary
Skin: The patient reports no changes in skin texture or color, itching, skin lesions, or excessive bruising. The patient says that he spends six hours in direct sunlight. He uses SPF 50 sunscreen.
Hair: Reports no changes in hair texture or hair loss.
Nails: Denies changes in nail texture and color, cracking, and splitting.
Head: Patient denies any headaches, recent surgery or injury, concussion, dizziness, and history of consciousness.
Neck: The patient denies any neck pain, stiffness, or masses. He also denies any lymph node enlargement.
Eyes: The patient is shortsighted, and he wears corrective lenses. He denies any history of eye injury, discharge or pain, flashing lights, or light sensitivity. He reads without difficulty when he wears lenses.
Ears: The patient’s last hearing test was on 08/2020. He does not report any changes in earing, vertigo, drainage, ear pain, tinnitus, recurrent ear infections, or excessive wax problems. The patient does not use any hearing aids.
Nose, Nasopharynx, Sinuses: The patient denies any frequent nose bleeds, postnasal drip, nasal discharge, sinus pain or infections, changes in smells, allergies, or use of recreational drugs.
Mouth/Oropharynx: Patient denies any mouth sores, sore throats, bleeding gums, changes in voice quality, hoarseness, change in taste, difficulty swallowing or chewing, dentures, and bridges.
Respiratory: The patient denies any pain with breathing, frequent colds, coughing, hemoptysis, or dyspnea. The patient reports smoking cigarettes once in a while
Cardiovascular: The patient denies any palpitations, edema, coldness of extremities, dyspnea, hair loss on legs, paresthesia, sores that do not heal, and leg pain with activity. He, however, states that he starts feeling “pressure” when he misses his medications.
Breasts: The patient denies any breast lumps or masses, nipple discharge, pain, changes in appearance, breast surgery, or cystic breast disease. The patient reports not performing any breast self-examinations. He does not recall when his breasts were last examined.
Gastrointestinal The patient’s last fecal occult blood test was done on 08/2017. His last colonoscopy was in 2018, which indicated that he had GERD. The patient denies any changes in appetite, jaundice, pain, diarrhea, constipation, flatulence, or nausea. He, however, has frequent heartburns and abdominal pains.
Genitourinary: The patient experiences nocturia, but this does not affect his sleep quality. He denies any pain in urination, burning sensation, hesitancy, inconsistency, changes in the urine stream, excessive urinary volume, blood in the urine, or decreased urinary volume.
Female/male reproductive: The patient is sexually active. He is in a heterosexual relationship with his wife, who is his only sexual partner. The patient had a vasectomy in 2007, so his wife does not use any contraceptives. He denies any prostate problems or impotence. The patient prohibits any discharge, pain, or masses on his pain. He reports a decreased sex drive. He has no history of STIs or sexual intercourse. The patient’s last prostate exam was done on 08/2020, and the results did not indicate any prostate enlargement.
Musculoskeletal: The patient denies any muscle pain, joint pain or swelling, fractures, stiffness, back pain, limitations in mobility, or loss of height. The patient reports that he has general muscle weakness.
Neurological: The patient fainted once in his office due to work fatigue. He, however, denies any pain, seizures, changes in memory or cognition, sensory deficits including numbness or tingling sensations, and problems with balance, gait, or coordination. He denies any tremors or spasms.
Psychosocial Profile
Health practices and beliefs/self-care activities: The patient rides his bike every evening after work. He does self-examination twice a week in the mirror; he brushes his teeth thrice a day and flosses twice weekly. The pressure has a blood pressure monitor, which he reports using every night after work.
Nutritional patterns: The patient reports having a normal appetite. He has two meals daily, missing his lunch due to his busy schedule. He takes around five glasses of water a day. He does not measure his water intake. In the past twenty-four hours, he consumed tea, a packet of yogurt, chicken breasts, and mayonnaise. For dinner, the patient ate roasted potatoes and hamburgers.
Functional Ability: The patient reports having no problems with activities of daily living. He can dress, eat, bather, toilet, shop, drive, and cook indecently.
Sleep/rest patterns: The patient admits to getting eight hours of restful sleep per night. He rarely takes naps. He denies using any sleep aids.
Personal habits (tobacco, alcohol, caffeine, and drugs): The patient denies drug use. He smokes tobacco once in a while. Roughly one cigarette per week. He consumes tea daily. He does not drink any alcohol.
Environmental history: The patient lives in their condo with his wife.
Family/social relationships: The patient lives with his wife and 18-year-old daughter.
Cultural/religious influences: The patient is a Roman Catholic but denies any power of his religion in his medical decisions
Mental Health: The patient denies any anxiety or depression. His job is, however, stressful, and he copes by talking to his wife about his stress.
Now answer the question below:
Using the instructions below, identify one physical strength, one psychosocial/cognitive strength, and one weakness in either category. State why you think this to be true.
Physical Strength: The patient has a good nutritional intake. He is also physically active. He has no impairments in his mobility. He can independently carry out the activities of daily living without any issues.
Psychosocial/Cognitive strength: The patient is detail-oriented. He keeps all his medical records, such as current medications and a list of doctors, in his wallet. He has good stress-coping skills. He talks to his wife about his stressful job. He is happily married, with friends who admire and support him.
Weakness: The patient’s fault is that he works too hard. He is the Chief of Surgery and, hence, extremely busy. He does not take any off days and, therefore, has no vacations. He reports that his wife told him, “His, job is like a second wife.”
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Question 
Purpose of Assignment: The first part of a health assessment is the history. It contains critical information about the client. It is important for the nurse to feel comfortable asking all types of questions and to be able to identify the pertinent information for that client. This assignment is a comprehensive health history normally done for a new client to practice or admission.
Comprehensive Health History
Course Competency(s): Identify the foundations of health assessment.
Instructions: Using the provided form to guide the interview, collect as much information as the client is willing to divulge. In a combination of bulleted and narrative formatting, document the information gathered. Try not to be too wordy, but, at the same time, be comprehensive in your documentation. Remember, this is subjective information and should only be what the client tells you. Avoid making judgments until you determine what the strengths and weaknesses are. Submit this as a Word document.