Health History
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Miami Dade College, Kendall *
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506
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History
Date
Nov 24, 2024
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docx
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Running head: HEALTH HISTORY
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Health History
Gabriel Gomes
Miami Dade College
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Running head: HEALTH HISTORY
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Health History
Introduction
Health history refers to the comprehensive assessment of all factors influencing an
individual's health. While conducting health history, providers of care evaluate patients' medical,
surgical, social, cultural, and familial backgrounds to assess the effects of deviations on their
health or their families. Alternatively, health history helps nurses evaluate patient, and family
teaching needs as well as make it possible to individualize the plan of care to improve health.
This assignment will perform health history on a patient, E.L, who presents at a facility with
complaints of headache, generalized body weakness, and feelings of dizziness.
Patient Interview
Demographics
E.L is a 39-year-old woman of Latino origin, born and raised in Cimarron village in
Colfax County, New Mexico. She currently lives in Miami with her husband of 10 years, and
together they have an 8-year-old boy, Sunny. E.L works as a first-line supervisor of retail sales
workers, a position she has held for three years. She works for 8 hours every day for five days.
On certain days, she is forced to go for longer shifts, as well as during weekends. She visits her
parents back in Cimarron once every year.
Chief Complaint
E.L enters the assessment room, appearing weak and discouraged. In a feeble voice, she
says, "I'm not just feeling okay. I have been experiencing generalized body weakness, dizziness,
and severe headache for the last three days." The patient says she took some out-of-counter
medications, but her condition does not seem to improve. On a scale of 1 to 10, she rates the pain
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at 7. She is, however, concerned that her health is at an alarming rate. She denies having sought
healthcare elsewhere, apart from the few hydrocodone tabs.
Past Medical History
The patient affirms that she received all vaccines against common childhood diseases
while she was a child. E.L can only remember one admission into a medical facility after an
asthma attack 20 years ago. The asthma was resolved after four days of being admitted. She
denies suffering from any acute or chronic illness. Occasionally, she has experienced a headache
that resolved after taking analgesics. The patient has never undergone an operation, neither been
transfused. During her pregnancy, however, E.L was said to be anemic. This, too, resolved after
she enhanced her diet and took "some medications." She is not allergic to drugs or food and non-
food substances.
Current Health Status
The patient says her health is in tatters, although her general appearance is fantastic. She
cannot remember the last time she was in such bad condition. Apparently, the illness has
prevented her from going to work. She is also not able to perform routine house chores. Besides
the three-monthly family planning visits, E. L has never seen a doctor for a long time.
Family History
Both her maternal grandfather and grandmother died many years ago due to cancer and
chronic kidney failure, respectively. They were aged 81 and 77 years, respectively. Her paternal
grandfather is alive, although he suffers from hypertension and diabetes. He is 92 years old. Her
maternal grandmother recently died of the complications of Covid-19. Until her death, she had
arthritis and Alzheimer's disease. She was aged 85years. Both E. L's parents are alive. Her father,
63 years, was recently diagnosed with type 2 diabetes. He is an alcoholic and smokes at least two
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Running head: HEALTH HISTORY
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packs of cigarettes daily. He developed this habit almost twenty years ago. Her mother is 57
years old and has no medical condition. E.L is the firstborn in a family of two girls and three
boys. Of the five siblings, four are alive. One of her brothers died in a tragic road accident more
than eight years ago. The rest of the siblings are healthy, save for one with hearing loss. E. L's
husband is 44 years old and suffers from low back pain and gout. Their son is healthy, with no
history of illness.
Personal & Social History
E. L moved from her home in New Mexico to Miami 17 years ago. At this time, she lived
with her aunt as she attended school. Three years later, she moved to her own house after
securing employment as an administrative assistant. She has since changed jobs three times
before she became a supervisor. She got married 12 years ago and conceived their son at 27
years. Her current employment is very demanding. She wakes up every day at 5 am and sleeps at
11 pm. She must be at the workplace from 7 am to 5 pm, although sometimes she is forced to
extend up to 9 pm. She admits that she hardly gets sufficient time with her son, whom she loves
so much. Other than her current stressful work, E. L has recently become worried about her
parents, who recently tested positive for the Covid-19. Her husband was retrenched three months
ago because of the Covid-19 pandemic. She is the sole provider for the family and her parents,
considering that her husband was retrenched three months ago.
She leads a hectic life and hardly finds time to exercise or eat a balanced diet. Of late, she
admits to being consuming fast foods. She attends church every Sunday, although she does not
participate in their significant events or functions. She does not remember the last time she
hanged out with friends or other members of her extended family. She neither smokes nor drinks
alcohol. In her free time, E. L prefers sleeping or watching a movie or two.
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Review of Systems
E. L is of medium height and looks nervous. She responds to all questions asked
appropriately. Her vital signs are as follows: blood pressure is 120/69 mmHg, a pulse of 84bpm,
respiratory rate of 18, and axillary temperature of 100.8°F. She weighs 121 lbs. and a body mass
index of 25.1. Her head is round and covered with neatly prepared dark hair. Other than the
headache and feeling dizzy, there are no abnormal features on her head. She has had not
encountered any trauma on her head in the past. Her eyes, ears, and nose are symmetrical and
equidistant from the midline. There are no squints, otorrhea, or nasal flares and polyps. She has
good vision, sense of smell, and taste. She admits to not having visited an optician or dentist in
her entire life. All teeth present; no foul smell detected.
She moves her head in both directions with some difficulties. The thyroid gland is of
normal shape and size. There are no spinal deformities, tenderness, or hematoma. Her hands are
equal in length, with no scars. The palms are warm and moist. On her chest, there are no wounds
or scars. Both breasts are present, equal in size and shape. There is no nipple discharge. Neither
is there distress nor pain while breathing. There are no crackles, wheezes, or any abnormal
sounds upon auscultating. She does not report any incidences of chest pain or shortness of
breath. She had some coughing episodes that resolved two weeks ago. The back is continuous
without scars, swelling, or tenderness.
The abdomen is round without any scars. Striae gravidarum is present. The abdomen
moves with every respiration. No abdominal distension was noted. Palpation of the abdomen
produces a dull sound. The patient was not comfortable with me assessing her genitalia or
rectum. She said everything down there was okay, considering that she visited a family planning
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clinic once every three months. She did not report any problem with her reproductive system.
She was sexually active and received her periods regularly.
Further, she noted that she did not have any problem with micturating or passing stool.
An assessment of her lower extremities did not indicate any problem. The legs were equal in
length and did not have scars, edema, or noticeable varicose veins. All the peripheral pulses
could be felt. All reflexes could be elicited.
Despite most of her systems having no issue, E. L claimed she was lately becoming too
tired to complete routine tasks. She sometimes found it hard to fall asleep, only waking up
finding herself weaker and weaker.
Nutritional Assessment
To start with, E. L is not concerned about her nutrition. Her mind is preoccupied with
other things around her life that she forgets about healthy diets. Even though E. L consumes fast
foods, and her BMI indicates she is healthy. However, she is at risk of becoming overweight and
obese if we take into consideration the prevailing conditions around her. Before coming to the
hospital, the patient admitted to having eaten Cinnabon's Pizzabon and felt just okay. She does
not care so much about the amount of calories she consumes in 24 hours. On particular days
though, E. L confessed to preparing balanced diets and incorporated green vegetables and fruits
for her family. She feels there is a need to change her eating habits in the future.
Risk Factors
E. L is at risk of becoming obese and developing lifestyle diseases like those affecting the
cardiovascular system. She is also at risk for depression because of her parents' covid-19 status
and her husband's retrenchment. These factors have put immense pressure on her, being a
breadwinner. Also, her family history reveals that type 2 diabetes runs in their blood. Both her
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father and paternal grandfather have diabetes. Her risk for type 2 diabetes is increased because of
her dietary habits and sedentary lifestyle.
Health Promotion
Putting into consideration the patient's chief complaint, family history, job demands, and
issues affecting her presently, it was agreed that she would do a full blood count to determine the
levels of blood components. A nonresponsive headache could either suggest low levels of
hemoglobin or something else. The patient could also be suffering from depression due to the
strain she experiences to provide for family and parents. It is also evident that she demands at her
workplace are intense, hence the generalized body fatigue. The health promotion strategies will
be based on these factors.
E. L may need to take a break of a few days from her job to see if her health improves.
Alternatively, she may need to request her seniors to assign her less demanding tasks considering
her deteriorating health. She also needs to find time to go out with her family and friends not to
suffer from burnout. By spending time out, she will find it easy to switch her mind off her work
demands. She will breathe fresh air and enjoy things that are not close to the workplace.
E. L is also encouraged to visit a psychologist to handle her depression. A qualified
psychologist will enable her to have a complementary view of life despite the current
happenings. Having numerous thoughts about life is known to cause unresponsive headaches in
people. E. L is worried about her parents' safety, job demands, and being the sole breadwinner
for her family and parents.
The patient should also be reminded of the importance of eating a balanced diet and
drinking at least eight glasses of water in 24 hours. A balanced diet consisting of carbohydrates,
proteins, minerals, vitamins, fiber, fruits, and water leads to excellent physical and mental health.
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It also increases the body's ability to work as well as resist and fight diseases. She needs to pay
attention to what she eats, especially considering her family history. Fast foods may be tasty to
eat but do more harm than good to the body. There is no doubt that her health will improve if
these factors are taken seriously.
Genogram
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