Health History

Health History Assessment Author's Name The Institutional Affiliation Course Number and Name Instructor Name Assignment Due Date Health History Assessment Before a patient can be put on any nursing care intervention plan, the nurse has to evaluate them to see what they need. Caregivers can get factual and subjective information from patients through nursing evaluation to determine their health goals. Kurniawan and Hariyati (2019) say that evaluating patients is essential to care delivery because it leads to better nursing care and patient results. Any plan that makes patients safer could lead to better benefits for patients. This means that nurses' jobs depend on how well they are taught to test patients. A sample nursing test is used in this study to find the connections between subjective information that impacts health and wellness. The essay aims to show and share what is known about the topic and teach readers how to deal with a medical evaluation. Demographics According to the instructions, demographics were written down (Jozaghi, 2019). Kindness A long-distance friend decided to take part in this evaluation. The participant was told what the evaluation was for and when it should be finished, and they chose to proceed. The patient will be known only as "A.N." for this task to protect privacy. A.N. is a South Asian man born on November 20, 1994, and is 30 years old. He was born and raised in India. When he was ten years old, his family moved to the United States. The patient can be understood when they speak English. He went to college. Right now, he works as a mechanical engineer in the auto business. He is straight and not seeing anyone right now. The patient needs insurance but has not had it in a while. Perception of Health It is hard to judge health states because people's ideas about their health might not match doctors' (Sen, 2022). The patient said that because health and well-being differ, asking them is the only way to understand optimum health. One of the health factors he thinks is wrong is the BMI calculation. He said he does not think he will ever reach the weight his BMI recommends for his height and age since he is 5'11" and 250 pounds. He thinks his poor health means he needs to start eating better and changing his daily routine. He wants to lose weight and thinks eating healthy foods will help him. Past Medical History The patient's past medical history was recorded using the peculiar guidelines that are important for history collection (Nichol et al., 2023) Childhood Disorders The patient cannot remember ever having any childhood disorder. Past Injuries The patient claims he ruptured the ACL (anterior cruciate ligament) while playing football when he was fifteen years old. He obeyed the doctor's advice and stopped playing sports for a while to allow for proper recovery. Chronic Illnesses The patient believes he has depression as well, but he never went in to get diagnosed. The only significant, long-term illness he has been diagnosed with is hypertension. Operations The patient has only had one operation in his life, which was the removal of his lower left third molar (wisdom teeth) at the age of 25. Immunizations The patient confessed he had never received the COVID-19 or flu vaccination, even though he admitted that there was a risk that he was not fully immunized. Allergies The patient suffers from seasonal allergies; triggers include pollen, mold, and dust mites. Current Medication in Use The patient takes the hypertension medication his doctor has prescribed daily. Family Medical History The patient's family medical history was written down using the special rules needed for history taking (Nichol et al., 2023). A.N. says that his family is in good health overall. The 58-year-old mother of the patient has been diagnosed with high blood pressure. After his younger brother died in a sad accident, the patient's 65-year-old father was told he had type II diabetes mellitus. The person with high blood pressure has two brothers. Her 34-year-old sister had high blood pressure in the past but got better after making significant changes to her diet. The brother, who is now 27 years old, finished treatment for lung cancer by the time he was 20 years of age. He has not had cancer since. The patient says that his 87-year-old paternal grandma has dementia. The patient also says that his grandpa on his dad's side died at age 74, and it did not look like he had any health problems. The patient also says there are no known health problems and that his mother's parents. His maternal grandfather is 89 years old, and his maternal grandma was 69 years old when she passed away with no signs of medical issues. Review of Systems (ROS) The ROS of the patient recorded under a specific pattern has been listed below (Phillips et al., 2017): General Health: The patient is currently 5 feet 11 inches tall and 250 pounds. At 34.86, his BMI, the patient is classified as obese. Admittingly, the patient weighed 187 pounds about three years ago. He understands that he has to drop weight because it has gotten out of control. The patient says he is always exhausted but thinks his food and weight are the causes. A.N. disputes having a temperature, chills, perspiration, or night sweats.Skin, Hair, and Nails A.N. claims to have never had any skin issues. He claims to apply sunscreen routinely and limit his total sun exposure. The patient contests changes in their skin, hair, or nails and claims they are all standard. Endocrine System The patient disputes having ever had diabetes, its symptoms, thyroid issues, uneven hair distribution, changes in skin tone or texture, or excessive perspiration.Head The patient opposes having vertigo, convulsions, or headaches. Neurologic System When asked about their history of seizures, strokes, fainting, or blackouts, the patient opposes any of them. The patient further rejects having any issues with his motor, sensory, or cognitive functions. The patient acknowledges that, while not a recent event, he does feel down. The patient claims he is not thinking about suicide, feeling hopeless, or wanting to terminate his life.Eyes The patient reports wearing prescription glasses for over ten years, each pair having a perceptual index of -2.00. He says his eyes are bothering him. The patient disputes h...