Comprehensive health history

Posted by Melda Research on February 1st, 2019

  1. Identifying data.
    Name: Mendoza Rachael
    Sex: Female
    Age: 65
    Phone Number: + 1857 239 0557
    Address: Missouri City, Texas
    Date of birth: January 9th, 1950
    Marital status: Widowed
    Occupation: Housewife

Source of income: She depends on Social Security. She has recently received Medicare coverage for her health insurance. She lives with her son and his family who cater for her health concerns and lifestyle support.

  1. Past medical history.

              The patient is visiting the hospital complaining of a consistent backache that is interfering with her daily activities such as dressing, walking, bathing, eating, Toileting and continence (ADLS). The pain has persisted for two weeks. Pain is at the lower lumbar area. It feels like a throbbing like pain occurring throughout the day. The pain severity is eight on the pain scale of 1-10. She has to lie frequently down or sit until the pain improves. The pain duration is about fifteen minutes and not moving or standing relieves the pain.

         The first incident of the symptoms started when she was bending while cleaning. It started to reoccur on a daily basis. Her health history indicates that she as cholesterol and borderline blood pressure that are controllable through medication.

  1. Health status

The perceived barriers and support

          The patient feels tired and prefers to lie down. The patient during the nights wakes up to visit the bathroom. She eats healthy foods with no junk. Her overall health is good. She likes when she can do all the things independently without depending on others. The client does not have any medication or food allergies. During childhood, she was diagnosed with chicken pox and bronchitis. There is no reporting of any serious chronic illnesses. She has also not had any past injuries or accidents but reported past hospitalizations and operations. She had a Thyroidectomy on March 1986. The second operation was a Hysterectomy in August 1989. She had cataract removal from her eyes in 2003 and 2007 in an outpatient surgery.

            She is currently using the following drugs Simvastatin 20 mg for cholesterol control during bedtime, Levothyroxine 175 mg for Thyroid one daily and the blood pressure drug Atenolol 100mg daily. The Medicare insurance covers the costs of these medications. The patient mentions that these medications are helping her, and she does not experience any side effects from them. She takes the medications religiously.

  1. Chief complaint (CC)

            She complains of a backache in the lower lumbar area

  1. History of present illness (HPI)

The constant backaches began two weeks ago when the patient was cleaning her clothes.

  1. Family and social history (PFSH)

          The patient’s husband died from a heart attack in 1985. She has two girls and two boys. They live with their partners and children here in the USA. All the members of this family are in good health. One of the sons whom she is living with has cholesterol while one of the daughters has high blood pressure. Both children are putting their conditions under control, through good diet, exercise, and medication.

           According to the patient, all her children do not drink mainly because of religious reasons. Sometimes the client suffers from mild arthritis in her joint that may be caused by age. The patient and family members have reported no to the following conditions; Breast Cancer, Asthma, Blood Disorder, Allergies, and Kidney Diseases. Others are Heart Disease, Cerebral Vascular diseases, Mental illness, and immunological disorders, Tuberculosis, Seizure Disorder and Obesity.

7. Focused review of systems (ROS).


          Her weight has remained steady for months by 150 lbs. She reported tiredness and weakness that does not go away even after resting. She does not experience night chills or sweats.


           The patient reports that she does not have any skin problem. She has a normal skin tumor and no bruises. Her skin is intact, dry and clean. She uses skin cream and does not expose her skin to sun rays by covering herself.


          There is thinning of her hair because of age. Her hair texture is normal with no any changes. She shampoos, and conditions her hair ones a week and takes a birth daily.


        Notices nails are brittle, but their shape and color have not changed. She applies lotion and Vaseline to cuticles and nails to prevent dryness.


         Client reports that she does not experience any dizziness, headaches, vertigo, syncope or head injury.


           She reports that her vision is good since the cataract surgery. She does not have blind spots, blurring, pain diplopia, discharge, swelling or redness, and watery eyes. The client wears eyeglasses and goes for a frequent eye check up.


           No ear infections earaches or discharge. She has good hearing and no vertigo or tinnitus. Cleans her outré ear with a wet cloth and does not clean inside the ear canal. She closes her ears in cases of loud noise.

Sinuses and Nose

Cleans regularly nose with water and blows her nose gently

1. Throat and Mouth

2. Client reports that she does not have any pain inside the mouth and no sore throat. Her canine decayed tooth was removed, but he still suffers from a toothache. No lesions and sores on tongue and mouth. No taste alteration, tonsillectomy, hoarseness, and dysphagia.

Goes for dental checkups semi-annually and brushes teeth twice a day

Neurologic system

       The client does not have a history of stroke, seizure disorder, blackouts or fainting. She has no tremor, weakness coordination problem, paralysis, difficulty in swallowing or speaking. She does not experience changes in mood. She has no Memory disorder or a mental health disorder history. The client is friendly and pleasant. She reads the Bible and Christian books.

Endocrine system

       Her glucose level was at a normal rate according to the reports from the client’s last checkup. She uses medication to control her cholesterol and blood pressure. She eats healthy foods.

Axilla and Breast

          Patient reports not to have any skin changes, pain, swelling, tenderness discharge or dimpling or any surgeries.

Respiratory System

       Client says she does not have any chest pain, lung disease, breath shortness or wheezing. She experiences flu and mild cold depending on the weather and lasts for a few days.

Cardiac system

          Client reports not to have any chest pain or cardiac disease apart from the blood pressure. She visited her primary care physician in August 2015 and results were normal.

Interpreting health status

         The patient has a strong support system from friends, family, and church. She knows that since her husband died of heart attack and her children may be prone to acquire heart diseases. The critical illness is cholesterol and blood pressure.

Techniques for history taking

           Appearance and Demeanor are a face to face communication between nurse and patient (Harmanjit, 2011). It involves the observation of body language and physical appearance. This technique is effective because it involves taking notes of patient’s feedback (Rhoads and Petersen, 2012). It has to be in a proper environment (Eagle, et al., 2009The second technique is learning about the current illness (Sanders, McKenna, and Lewis, 2011). The third technique is questioning whereby the nurse follows the patient’s lead. It has the limitation of becoming too wide (Sanders, McKenna, and Lewis, 2011).


Eagle S, Brassington, C, Dailey C and Goretti, C . 2009. The Medical Assistant Teamwork-Based Integrative Approach. F.A. Davis, p 307

Harmanjit H. (2011). Clinical Examination: A Practical Guide to Medicine. Jaypee Brothers Publishers, p 51

Rhoads, J, and Petersen, S (2013). Advanced Health Assessment and Diagnostic Reasoning. Jones & Bartlett Publishers, p 121

Sanders, M, McKenna, K and Lewis L. (2011). Mosby's Paramedic Textbook. Jones & Bartlett Publishers, Chapter 18.

Sherry Roberts is the author of this paper. A senior editor at MeldaResearch.Com in College Essay Writing Service if you need a similar paper you can place your order from cheap essay help online.

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