Comprehensive Health History TakingNameInstitutionInstructorCourseDate Comprehensive Health History TakingComprehensive health history is a basic function for competent nurses, which provides information to help the nurses in making informed decisions in relation to a particular patient. This will influence the treatment process and the overall outcome of the treatment process (Bickley, Szilagyi, & Bates, 2013). There are seven components involved in comprehensive history taking which are data identification, chief complaint, history of present illness, past history, family history, personal and social history, and a review of systems (Bickley, Szilagyi, & Bates, 2013).
Identifying DataThe patient is a 28-year-old single male born in the United States and a practicing lawyer in the State of Texas. The source of the history is the patient who was referred by the family doctor. The admission date was 06 June 2018.Past Medical HistoryChildhood sicknesses1995: Chicken pox. 1998: Measles. 2000: Broken leg. Immunizations1992: Measles vaccine at a young age.
1992: Tetanus vaccine. PsychiatricThe patient has not suffered any psychiatric illnesses. Surgical history1998: Abdominal surgery to correct abdominal hernia. 2012: Hemorrhoid surgery.2015: Surgery to remove kidney stones.2016: Surgery to correct a leg injury.Health Status, Perceived barriers, and support2016: Diagnosed with hypertension where he began medication but later was able to control the condition with a change of lifestyle, which includes exercise and a change of diet. 2012: Diagnosed with Asthma.
MedicationsFluticasone-salmeterol: Inhaler, which is used during a severe asthma attack.Theophylline: Used to keep airways open by relaxing muscles around the airways.Chief ComplaintConstant headaches and blurry vision.History of Present IllnessThe patient has experienced constant headaches, which are more serious at night. The headaches are severe at the fore head near his eyes.
The headaches have been increasing, as they were mild at the early stages but have become more severe and serious which have led to the patient taking a temporary leave from work to take time to rest at home. A few days ago, he had a severe headache, which made him unconscious. He woke up after three hours confused and had nausea.
The headaches are experienced on daily basis, which have affected his normal activities including sleeping at night. His problems increase at night due to the light from his house bulbs, which have resulted to him switching off the lights to cool down the headache. Over the counter painkillers, provide a short-term solution. Other symptoms include fever and blurry vision. The patient has never experienced these symptoms before and he is worried about losing his sight or having other underlying health problems like high blood pressure, which his father suffered from. He needs assurance of the reasons for the cause of the headaches and the blurry vision. The patient does not smoke or drink alcohol and does not suffer from other medical conditions apart from hypertension, which was diagnosed 2 years ago.
There is a family history of hypertension.Social HistoryAlcohol use: Alcohol use at the early stages of his life but later quit after diagnosis of hypertension. The patient does not smoke or use illegal drugs. The patient takes foods with low cholesterol in the management of hypertension and exercises thrice a week. Family HistoryPatient’s father died at the age of 70 due to complications of hypertension and diabetes. His mother is 65 years old, alive, and suffering from hypertension and diabetes. The patient has three siblings who are two brothers, and one sister who has hypertension. The family history indicates a positive history of hypertension and diabetes.
Focused ReviewGeneral: Decreased weight, which happened in recent days, weakness due to the sudden weight loss.Skin: Skin rashes present and dry skin.Head, Eyes, Ears, Nose, and Throat (HEENT): Head: Constant headache, dizziness, was unconscious at sometime. Eyes; Blurry vision, flashing lights. Ears: Normal hearing, no infection. Nose: Frequent colds and nosebleeds. Throat: Normal teeth and gums, no bleeding gums, never been to a dental examination.Neck: No lumps, goiter pain, stiff neck or pain.
Breasts: No breast lumps or pain, no discharge.Respiratory: No cough or blockage of airway, no pneumonia of tuberculosis.Cardiovascular: Hypertension, which is under control, no chest pain.Gastrointestinal: Normal bowel movement and no constipation, good appetite, no diarrhea.Peripheral vascular: No history of arthritis or leg pain.Urinary: Normal frequency of urination, no pain during urination, report of kidney stones.Genital: Reported abdominal hernia, no scrotal pain, no history of sexual transmitted diseases.
Musculoskeletal: pain at joints and back. Cannot perform back exercises or lift heavy objects.Psychiatric: depression due to the fear of developing hypertension and diabetes.Neurologic: Weaknesses present, fainting reported, good memory functioning, dizziness, seizures.Hematologic: No anemia, has had two blood transfusions.Endocrine: sweating at night.Age, Spiritual Values, and Cultural Variables That Were Considered and How These Variables Influenced Your Interviews or Health HistoryAgeThere are diseases, which are related on individual’s lifestyle, which is directly related to their age. These diseases include heart diseases, diabetes, and some types of cancers (Bickley, Szilagyi, & Bates, 2013).
Some of these diseases may be managed in young people. Age is a major consideration in deterring underlying medical conditions and is mostly the first question by a healthcare practitioner in the collection of information relating to a patient (Bickley, Szilagyi, & Bates, 2013). Age influences a healthcare interview by influencing a healthcare perceptions relating to particular diseases and behaviors. Age also determines the interaction between the healthcare professional and the patient as healthcare professionals relate different to different age groups (Bickley, Szilagyi, & Bates, 2013). Spiritual ValuesSpiritual values are mental aspects relating to the spirit and the human soul, which influence individual’s decisions and perceptions on different aspects, which may affect them (Rudolfsson, Berggren, ; Da Silva, 2014). Spirituality experiences shape the perceptions that patients may have relating to diseases. Spirituality can influence the healthcare outcomes and the perceptions relating to a certain type of diseases and other health problems (Rudolfsson, Berggren, ; Da Silva, 2014).
Spiritual values also influence the human behavior and affect the strategies to implement in addressing a specific medical condition. Information shared with physicians may be affected by spiritual values, which may influence personal information provided by the patients (Rudolfsson, Berggren, ; Da Silva, 2014). Many patients are not comfortable sharing their sexual lifestyles, which may affect their health status based on spiritual values.Cultural VariablesThese are systems, which are based culturally to explain causes of diseases and family health histories (Fishman, Cullen, ; Grossman, 2014). These processes also provide intervention strategies to diseases and who should be involved in the process. This influence of culture determines patients’ reaction to information relating to their health and what strategies to implement (Fishman, Cullen, & Grossman, 2014). Culture also influences patient compliance including providing personal information during history taking. Some patients may be hesitant to give out information relating to their families (Fishman, Cullen, & Grossman, 2014).
Some may require undertaking consultations prior to giving out their personal information relating to their health. Health care practitioners should be cautious and skilled to avoid unconscious bias. Health care professional collecting health history should communicate effectively with patients from different backgrounds to enable an effective interview (Fishman, Cullen, & Grossman, 2014).Address How to Elicit the Patient’s Interpretation of Their Health Status, Their Perceived Barriers, and SupportHealthcare professionals can prompt patients to interpret their health status, their perceived barriers, and support by helping patients in determining any confusing symptoms as a medical interview is a diagnostic tool, which can be used to determine underlying diseases (Bickley, Szilagyi, ; Bates, 2013). With a good communication process, a healthcare can enable a patient in interpreting their health status. Good communication establishes a close and harmonious relationship between the patients and the healthcare professional (Bickley, Szilagyi, ; Bates, 2013). A health care professional should also have good interviewing skills to enable effective interviewing. Effective interviewing skills involve the required knowledge and right attitudes, which will facilitate the patient’s interpretation of their health status, their perceived barriers, and support (Bickley, Szilagyi, & Bates, 2013).
Effective interviewing provides healthcare practitioners with more knowledge about the patient, which can be used to provide more insight to the patient regarding their health status, their perceived barriers, and support (Fishman, Cullen, & Grossman, 2014). The healthcare practitioner can also provide more details regarding the next step in addressing the patient’s health status. During the interview, the healthcare practitioner can also expound and explain any questions by the patients in order to clarify any misunderstood symptoms or information (Fishman, Cullen, ; Grossman, 2014). Critique the Effectiveness Of Several History Taking Techniques With Rationale From The ReadingsMajority of history taking techniques have been criticized for being difficulty to use, as they require more clinical skills to apply (Bickley, Szilagyi, ; Bates, 2013). This is because history-taking techniques require that physicians have both intellectual as well as emotional skills to better use these techniques (Bickley, Szilagyi, ; Bates, 2013). These skills are important as they provide a close and a good relationship between the healthcare practitioner and the patient, which is necessary for an effective interview (Bickley, Szilagyi, ; Bates, 2013).
These tools’ effectiveness is also determined by a healthcare’s experience, as they cannot be learned in school. For a better knowledge and skills on how to apply them, physicians must engage and use them in their clinical process with effectiveness reduced for new healthcare practitioners with less knowledge on their application (Bickley, Szilagyi, ; Bates, 2013). Majority of the history taking techniques require special skills, which include interpersonal skills in addition to clinical knowledge (Bickley, Szilagyi, ; Bates, 2013). Interviews are engagements with patients and healthcare practitioners need to be skilled in interacting with their patients to enable a successful outcome of the interviews.
Majority of the history taking techniques have also been critiqued for social bias, which has resulted to computer-assisted history taking tools, which are more effective as patients are open to report on unhealthy lifestyle behaviors, which may be critiqued in medical interviews leading to social judgments (Bickley, Szilagyi, ; Bates, 2013). ReferencesBickley, L. S., Szilagyi, P. G.
, ; Bates, B. (2013). Bates’ guide to physical examination and history-taking.
Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.Fishman, J. M., Cullen, L. M., & Grossman, A.
(2014). History taking in medicine and surgery. Knutsford: PasTest.
Rudolfsson, G., Berggren, I., & Da Silva, A.
B. (2014). Experiences of Spirituality and Spiritual Values in the Context of Nursing – An Integrative Review.
The Open Nursing Journal, 8, 64–70.