Course Project Milestone 1: Health History Form Your Name: Eva Hollingsworth Date: 1/28/14 Your Instructor’s Name: Professor Butler
Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language.
Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone1_Form_Smith” When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment.
Disclaimer: The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.” BIOGRAPHICAL DATA (10 pts) | | Date: | 1/22/14 | Initials: | V.H. | Age: | 40 years old | Date of birth: | August 10,1972 at 0801 in the am | Birthplace: | Einstein Hospital in Philadelphia, Pa | Gender: | Male | Marital status: | Married anniversary March 27, 2013 | Race: | African American | Religion: | Baptist all his life, believes in God, prays to God daily, and believes that God sent him his wife. Believes that his body is a temple and does not have any religious practices that effect his health care discussions. | Occupation: | Paper recycler in a factor, his job title is paper filler and 604 pulpier, has been at that job for 12 years. Melts the paper down by adding water and a chemical. Does not recall what the name of the chemical is at this time but, he said it does not smell. He has to use safety glasses when working and protective gloves. They have monthly disaster drills just in case there is a spill or any other emergency. He works eight hour swing shifts and is sometimes sleep deprived do to overtime which makes the job stressful. He misses a lot of activates with his family due to his schedule. | Health insurance: | Horizon Blue Cross and Blue shield, AmeriHeath was his previous coverage his job just changed company’s because it cost less for the new company. | Source of information: | Patient, he is awake, alert and oriented. | Reliability of source of information: | Self | PRESENT HEALTH HISTORY/ILLNESS (15 pts) | | Reason for seeking care: | Shortness of breath when running long distance. Runs three times a week. For the past five years and the shortness of breath started one week ago. Runs five miles regularly on each of those days and has only been able to run three miles due to his shortness of breath. The shortness of breath starts at mile 2 ½ but, is able to get another ½ mile in before he has to stop. He wants to be able to run his five miles again three days a week. The shortness of breath started one month ago. He does not finish running the rest of the two miles with the fear that his shortness of breath may get worse. He has not gained or lost any weight since the shortness of breath has started. | Health patterns: | He visits his primary doctor yearly for a physical and check ups. He does not take any medications except the occasional over the counter Advil for a headache and a daily multivitamin. He eats a different variety of fish weekly along with vegetables. He eats honey nut cheerios in the a.m. and a protein drink for lunch. He also runs three times a week. He does have the occasional beer but, generally does not drink. He does not smoke and has never smoked before nor does he do any illegal drugs. | Health goals: | He wants to be able to run his five miles again and eventually wants to participate in a triathlon next year in Philadelphia, Pa to support cancer research. | HEALTH BELIEFS AND PRACTICES (15 pts) | | Beliefs and practices: | Some of the beliefs and practices of health are eating a low fat diet. He does not eat fast food every week. When he eats out at a restaurant he orders chicken or fish. He believes that pork has too many hormones in it that are too harmful to the body. In the winter and flu season he has hand sanitizer with him at all times. He believes that he will get sick if he touches people’s hands in the winter. He does not have any culture remedies that he uses if he does get sick. He does sanitize his hands several times a day and takes a bath at work after his shift because he does not want to get any germs in his car. He rarely gets sick but, the last time he did get sick he will take an over the counter median until he feels better. He has not been to a doctor for a cold in so many years that he does not remember the last time he saw his doctor for a cold. He does believe that getting at least eight hours of sleep will help him get better. | Factors influencing healthcare decisions: | One thing that does influence his healthcare decision is his history. Over the counter remedies have always worked for him and he believed if he stays clean then he will not get sick. | Related traits, habits or acts: | He drinks at least one liter of water a day and never drinks soda or energy drinks. He believes that they hurt the body and water is the best thing for the body to have. | MEDICATIONS (15 pts) | | Prescription medications: | The patient cannot remember the last time he had a prescription medication. He said he must have been a child. He is usually very healthy. | Over-the-counter medications: | The patient takes dayquil or nightquil pills, dose is two pills as needed when he gets sick. For body aches and pain he likes Advil two pills as needed and he does take a multi vitamin but, not all the time. He does not take anything else that is over the counter. | Herbals: | He does not take any herbal medications. No teas or dietary supplements. He also does not take any folk remedies. | PAST HISTORY (15 pts) | | Childhood diseases: | The only childhood disease that he can remember having is chicken pox. | Immunizations: | The patient has had the following immunizations: HBV,DTap,Hib,IPV,PCV,Rota,HIB,MMR,HAV,TDAP,HPV and meningococcal vaccine. | Allergies: | He has no allergies that he is aware of. | Blood transfusions: | He has never had a blood transfusion but, does know that his blood type is A positive. He does donate blood every three months. | Major illnesses: | The patient has never had a major illness that he had to spend time in the hospital for. | Injuries: | He has had stitches in his forehead when he was five. He was trying to teach himself how to ride a bike and fell off and hit a brick flower bed. He received eight stitches in his fore head. There is a small noticeable scare. He broke his right lower part of his arm not sure witch bone when he was ten from falling off a skate board. | Hospitalizations: | He was hospitalized overnight when he was ten to have his arm fixed. That was the only hospitalization. | Labor and deliveries: | He has never been pregnant but, does have ten children that he has been in the hospital to see all of them born. | Surgeries: | The only surgery that he has had was to get his lower right arm fixed when he was ten, for a fracture. | Use of alcohol: | Will have a beer occasions, but does not drink every day and may go months without a drink. He will have a few drinks this Sunday when watching the supper bowel. | Use of tobacco: | Does not smoke and he has never smoked in the past. Believes that his body is a temple and smoking will damage it. He tries to stay away from people that smoke so he does not get any second hand smoke, he does not want cancer. | Use of illicit drugs: | Tried some illegal drugs when he was younger but has not done drugs in his adult life. Does not wish to discuss what the drug was or at what age. | EMOTIONAL HISTORY (15 pts) | | Mental, emotional or psychiatric problems: | The patient did experience an emotional upset when his father died. He started to have chest tightness at the hospital when he was given the news about his father. He saw a doctor in the emergency room at that time blood work was done. The diagnosis was emotional distress and anxiety from his father having died. No other test was done and he does not know what the blood work results were. Never had that problem again. | FAMILY HISTORY (15 pts) | | Father: | Father died in 2001. He was shot but believes that he had cancer of the lungs. All his hair fell out and he was very thin in his last years of his life. Hypertension is the only other thing that he knows of any health care problems. | Mother: | Mother has hypertension, high cholesterol and diabetes. She sees the doctor every month as she is instructed. | Siblings: | Have three siblings. Two are in jail and one he has not spoken to in over twenty years. Does not wish to talk any more about the situation. | Grandparents: | Never meet his father’s parents until his father’s funeral and does not know anything about them. Both of his mother’s parents died before he was born. He does no that his grandmother died of breast cancer and that his grandfather died from a knife fight. | PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts) | | Occupational history: | Has worked as a pizza delivery, an art work framer in a museum, then his current job. Only training he has had is on the job training. | Educational level: | Graduated from high school was going to go to college but had a son and started work right away. Speaks only English but, is learning Spanish from his wife. | Financial background: | Has not been poor but, both of his parents had a job and worked hard for a living. This has showed him to always work hard. Since he has been married his situation has become better him and his wife shares all the money. They have money saved for a rainy day that he was never able to do before. | ROLES AND RELATIONSHIPS (15 pts) | | Significant others: | He is married for eleven months does have children but, not by the new wife. The new wife does have two children ages seven and nine. His ten children live with their mother he does have visitation rights for the children and he does see them often. He is head of the family but, him and his wife split the duties of the children. His wife sometimes takes on a lot of responsibilities for the children when he works a lot. He does not leave a lot of time for him and his wife witch places a lot of stress on the marriage. | Support systems: | Wife is a good support person in his life. He also has his mother that does a lot for him and a few male close friends that he can count on for anything. | ETHNICITY AND CULTURE (10 pts) | | Ethnicity and culture: | He has lived in the United States his whole life and has never been to Africa before and does not plan on it. He is an American but, his ethnicity is African. He does make food like his African heritage but, his wife is Spanish and they follow a lot of her culture. | Physical and social characteristics that influence healthcare decisions: | The way he looks and feels influences his decision making. He is very fit and does not have much body fat; if something will make him unable to exercise and get fat he will not do that. But if it is a temporary thing he said he will try if it will make him better. | SPIRITUALITY (5 pts) | | Religious and spiritual needs: | He is a Baptist but, does not have any spiritual needs. He does pray every day for the safety of his family and believes that God does answer his prayers. God sent him his beautiful wife and he is very happy. | SELF-CONCEPT (5 pts) | | View of self-worth: | He is a good person and worries a lot about his family. He wants to have enough money to send all of his children to college and wants to be able to help anyone that asks him. He thinks he is over all pretty handsome and is happy with his life. | Future plans: | To run the triathlon and have a happy life with his new wife. | REVIEW OF SYSTEMS (20 pts) | | Skin, hair, nails: | Has no problems with hair, skin or nails. He takes a shower every day and some times more depending what he is doing that day or if he is around any one that is sick. Washes and conditions his hair every time he showers. He applies lotion after every shower to prevent dry skin and old age. Trims his nails weekly and cleans them as needed. | Head, neck, related lymphatic: | Has the occasional headache that is relieved by Advil. No history of any injuries to the head or the neck. No seizures tremors or dizzy spells noted. No swelling of the neck. | Eyes: | Has an eye exam every year for work and has 20/20 vision. | Ears, nose, mouth, and throat: | Denies any pain in the ears, nose, mouth or throat. Does have his annual exam of them when he gets his yearly physical. No problems eating or swallowing. Brushes teeth twice a day and flosses at night but, it has been a couple of years that he has had a dental exam. | Respiratory: | Denies having any usual repertory problems until recently, shortness of breath when he runs. No other problems noted. He does not smoke has not been out of the country recently to have caught anything. | Breasts and axillae: | Never had a breast exam. Never noticed any discharge or lumps in his breast. | Cardiovascular: | No history of heart disease, any palpitations or edema. | Peripheral vascular: | No high blood pressure, no numbness or tingling in the arms or legs. | Abdomen: | Has a bowel movement every day. No abdomen pain. | Urinary: | Denies any problems urinating. No UTI,uses the bathroom frequently every day. | Reproductive: | No reproductive organs, has no prostate problems. | Musculoskeletal: | Good range of motion; gets exercise every week. | Neurologic: | Gets a headache but, not frequently. No problems with falls or dizziness. He is right handed and can feel touch and temperature. |