Comprehensive Health History and Physical Assessment (Lab Report Sample)

Comprehensive Health History and Physical Assessment
Student’s Name
Institutional Affiliation
Comprehensive Health History and Physical Assessment
The patient is Mr. Harden, a 77-year-old man with a lengthy medical history of high blood pressure. He raised the concern with the chief complaint of increasing sharp chest pains below the sternum with a duration of ten hours. The patient presented himself, and he seems reliable. Additionally, the assessment relies on an old California Pacific Medical Center chart. The patient has a good memory and trusts me completely. Therefore, the information collected has a perfect score of 89%.
Past medical, surgical, and social history
Mr. M.N. Harden is a retired English literature teacher with a persistent history of high blood pressure, which was well managed before by diuretic treatment. He was first enlisted in the hospital in 2005 when he raised a complaint of sporadic mid-sternal chest pain. His heartbeat rate shown under the hospital devices at that time revealed severe atrioventricular obstruction, and a chest X-ray revealed minor pulmonary blockage, with enlargement of the heart. The patient was released after being put on medication of Lasix, digoxin, and enalapril for presumed congestive heart failure. From that day, he has often been monitored by his doctor. Apart from high blood pressure and his deteriorating condition, he explained that he was not aware of other heart disease risk factors, such as the intake of alcohol, cigarette smoking, excess cholesterol, excess fat, sugar, or salt intake, or family history for heart disease. He was okay until 10 p.m. on the day before hospitalization, where he experienced the start of severe pain in the breastbone, mostly while standing and sitting for prolonged hours. He took three tablespoons of antacid, but the situation did not change, though he did manage to sleep that night. The next day, he woke up feeling better until when he decided to take a walk around the neighborhood. The same pain returned, but this time, it was more intense. That is when he decided to call his son, who administered a painkiller and immediately rushed him to the nearest medical facility. He instantly received heart medications and thrombolytic therapy and was taken to the ICU unit.
Harden is currently on the following medication: Kcl 30mg once daily, digoxin 0.075mg twice daily, enalapril 30mg once a day, Tylenol two tabs two times a day as prescribed for arthritis, and Lasix 50mg once every other day
The patient reports increased pressure from clients who he supplies with fresh vegetable produce. He is concerned that the current condition is interfering with his normal activities. He takes three meals a day and drinks seven glasses of water daily. He also smokes half a packet of cigarette each day and rarely takes alcohol. Maybe wine on rare occasions and a bottle of whiskey in the company of other friends. No reported illicit drugs usage.
Previous condition
There are no abnormalities noted, but the client admitted to having experienced previous minor childhood illnesses. He suffered regular chest coughs, tetanus, influenza, and Lyme disease, though he has never contacted rheumatic fever. Growing up, he also had measles and chickenpox. He also reports to receive a polio vaccine at birth, and a flu vaccine annually. He is sensitive to penicillin and experienced a minor rash from an injection in 1993.
With blood transfers, he states that he received three units of blood in 1987 for GI bleeding, and Hepatitis B contamination complicated the transfusion. He also reports having had previous injuries, operations, and hospitalizations. They include a severe cut on the leg while planting corn on his farm, the gastrointestinal bleeding in 1985, a chest pain experienced in 2005, a check for abnormal cells, polyps, and ulcers done in 1996, and sutures for a laceration, done in 2010, after stepping on broken glass.
Family History
The patient was born in West Michigan and was raised by a single mother. His father left them at the age of 12, and mother passed away at the age of 55 from diabetes. His wife died four years ago of pneumonia and chest pain. The father later passed away at the age of 67 in a train accident. He had a single sister and two brothers, who have all died except for the youngest brother. The younger brother, 65, with hypertension, otherwise well; the other brother also died from a road accident twelve years ago; the lone sister, died recently from a complication during childbirth. The Daughter, 41, with mild arthritis, otherwise well; son, 33, with troubles;
Son, 37, is medically okay. No family history kidney or heart disease, tuberculosis, cancer, anemia, diabetes, epilepsy, or mental illness. He also has twelve grandchildren, six great-grandchildren.
Personal and social history
Brought up in West Michigan, he completed senior school at the age of 18. He then proceeded to college where he met his future wife. The got married three years later and had three children. He worked as a third-grade teacher back at home before relocating to California where he continued from where he left. The wife quit her job to raise their children, although fifteen years later, she returned to work because of financial challenges. After the death of his wife, he moved to a smaller apartment to be near his son. The son is not yet married and has that tendency of having many short relationships with older women. His daughter Mary is his favorite because she visits him regularly and cares more about his health. The problem is that her husband has an alcohol problem and Mr. Harden feels obliged to influence the decisions regarding his grandchildren directly. The grandchildren do visit him occasionally, and they enjoy playing with him and the jokes he makes for them. He has many friends who he grew up with but does not open to them about his health complications because they also experience the same.
The only time he gets to meet with many people is when he goes to his small farm to check on produce and supervise his workers. Some of them have grown to be his closest friends, and they like the way he treats them. Mr. Harden does no other exercise apart from walking around his farm. He strictly prefers a diet rich in carbohydrates and uses a sunblock.
Personal History
Mr. Harden lost his wife and lives with his younger son. He worked as a teacher to age 65 and is now retired. His regular routines indicate that he sometimes takes alcohol and smokes cigarettes, and does not adhere to any particular diet. Born in West Michigan, he relocated to Malibu in 1941 to pursue his dream of teaching. He has occasionally been outside of the United States. On two incidents, he traveled with his students to Germany for a singing competition. The last visit abroad was to Kenya, for a holiday in the coastal city of Mombasa. His present living condition indicates that he lives in a two-bedroom house on the ground floor of an apartment with an elevator. He does not have a home helper and relies mostly on himself and sometimes his son when he is around. The patient also has access to Medicare and social security and gets some extra income from the payments he gets from supplying fresh food products to the local supermarkets. His children also have set-up a bank account for him. They deposit a monthly contribution into the account, and he is allowed to make withdrawals for his daily upkeep plus other medical needs. Psychosocially, the man is described as engaging, active, and alert despite his arthritic symptoms. He is well aware that he is experiencing a “chronic complication” at the moment and seems to be remarkably worried
List of risk factors
A risk factor is any cause that enhances the possibility of getting a disease, especially chronic diseases. The non-modifiable risk factors are hazard inputs the patient has no influence over such as family history, race, gender, and age. Harden is white, the highest cultural group for blood pressure. He is seventy-seven, so his age exposes him to chronic conditions. The family background is a cause, because, his mother passed away in her fifties, from diabetes. The modifiable risk factors include lifestyle elements one has control over such as obesity, alcohol intake and or tobacco use. Harden is six feet two inches, and weighs two hundred pounds, giving him a body mass index of 39 which is regarded as unhealthy. A BMI of 39 increases his risk of high blood pressure. Harden occasionally uses tobacco use and takes alcohol. His intake for alcohol averages a drink in two days, which is not excessive, but still needs monitoring because alcohol increases the risk of developing blood pressure.
Review of systems
His energy measure is quite remarkable, and the weight is balanced at 200 lbs, height 6’2”
He reports to have never experienced frequent headaches. He mostly relies on vision glasses to read newspapers and thinks that his vision is not a problem at the moment. His skin has no rashes or any other changes. He also reports gradual disappearing of hearing ability, currently uses hearing aid. The nose shows no sign of oobstruction and epistaxis not present, no history of tinnitus, vertigo, infections. Harden has no history of asthma, wheezing, tuberculosis, or coughing, and no known heart disease. Last blood pressure test was performed in 1995. There is also no record of gangrene, claudication, aneurysm, or clotting deep in the veins. He reports to have been admitted to hospital in 1990 after four days of hematemesis and melena. Three months after this analysis it was discovered that he had complications with his liver. The blood transfusion he had undergone transmitted him with hepatitis B. Luckily, he underwent successful treatment, and the disease has never re-occurred. The patient does not experience hematuria or any abnormal fever...