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Health History of a Patient


The health history of a person reveals information about one’s health information. The health history of a person constitutes information concerning sicknesses, surgical data, immunization data, and outcomes of physical examinations. In addition, it contains information about medicinal d taken and health habits, such as diet and exercise. Inclusivity of patients’ close family members’ health information is part of the health history. The current and past illness information about the patient is a key component of the health history. This health history is a record of the information about a patient whom I interviewed while undergoing some medication in the hospital.


The elements that constitute patients’ demography include identification of information such as name, birth date, address, and insurance status. Demographic profile of the patient enables a clear billing process, and ensures the quality of the healthcare. In addition, demographic information aids in the enhancement of communication between the patient and the person conduction the interview.

Patients Information
1 Age 74 years old
2 Marital Status Single but lives with a family
3 Race Black African-American
4 Gender Female
5 Religious preference Christian
6 Height 62 inches
7 Weight 229 kgs
8 Reason for seeking care Complete Health Assessment

Perception of Present Health Conditions

Currently, the patient has been suffering from the following health condition: controlled HTN. Chronic Upper Respiratory Allergy, Chronic Pain due to Arthritis, Overweight, Dyslipidemia, longstanding GERD, Chronic severe pain of the bilateral knee.

Past Medical History

The table below shows the past medical history of the patient.

Health Condition History of Health Condition
2 Morbid Obesity
3 Osteoarthritis (OSA)
4 Impaired Fasting Glucose (IFG)
5 Dyslipidemia
6 Chronic Hyperkalemia
7 Chronic Pain Syndrome
8 Upper Respiratory Allergy
9 Acute DVT of LLE (Left Lower Extremity)

Family’s Medical History

The mother of the patient died at the age of 91 years. The mother had diabetes, hypertension, and dementia. The father of the patient died with unknown medical history. The patient has 4 healthy siblings. The patient has no track record of past surgical history.

Drug Amount
1 Losartan-hydroCHROthazide 100mg-250mg
2 Labetalol 100mg
3 Atorvastatin 40mg
4 Amlodipine 5mg
5 Fluticasone 50mcg/inch
6 Nasal spray
7 Allociterol
8 Cetirizine 10mg
9 Famotidine 20mg
10 Montelukast 10mg

Developmental Considerations

At the age of 74 years old, the patient met some of Erickson’s Stages of Psychosocial development and had also failed to meet some as the data in the table below shows. The perspective of developmental considerations of a patient creates a base for comprehending the nature of some childhood to adulthood disorders (Singh and Singh, 2001, par.1). The table below gives a summary of the requirements the patient should meet for each stage.

Erickson’s Stages of Psychosocial Development of the Patient  
Stage Psychosocial Crisis What happened to the patient Met/Not Met
1 Trust vs Mistrust Development of a sense of trust
2 Autonomy vs Shame Do things independently or doubt abilities
3 Initiative vs Guilt Initiate plans or feel guilty about efforts
4 Industry vs Inferiority A pleasure to apply to tasks or feel inferior
5 Identity vs Confusion Role testing or confused about who they are
6 Intimacy vs Isolation Form close relationships or feel isolated
7 Generativity vs Stagnation Contributing to society or lack of purpose
8 Integrity vs Despair Sense of satisfaction or failure (Adults)

The patient met the requirements for stage 1 where she depended upon parental care for everything. The patient developed trust in the caregivers (Cherry, 2021, par.7). Thus, the world was predictable at this stage. In stage 2, the patient was able to do things independently. Individuals at this stage gain little independence (Cherry, 2021, par.10). The patient felt secure in the world. The patient met the outcomes of the middle stages of Erickson’s Psychosocial Development but failed in the last three stages. The patient did not form close relationships with families because she felt isolated (Cherry, 2021, par.20). Isolation was due to the prolonged illness which made close friends and family members distance themselves from her. The patient failed to meet the requirements of stage 8 where she lacked a sense of satisfaction (Cherry, 2021, par.24). She considered herself a failure for not achieving much in life in terms of contributing to society.

Cultural Considerations

The patient explained more about her way of life. She revealed that she had a distrust of healthcare services provided by the clinical officers, she believed in other alternative medicines, she had a fear of the unknown, she had a strong belief in Christianity, liked the traditional medicinal drugs, dissatisfied with the healthcare services in modern hospitals and was unfamiliar with the concept of palliative care.

Psychosocial Considerations

The patient revealed her current mental health and well-being status which enabled me to assess her ability to function in the community. Some of her psychosocial considerations included: positive self-esteem, she had a sense of hope to live longer, and she related well with her family. In addition, the patient was emotional, had high mortality levels, and was not affected by the stress caused by mood changes.

Collaborative Resources to Improve Health

The collaborative resources to improve the health of the patient include the healthcare clinical professionals, the surgery and operational theatre, the instruments used, the rooms where medical consultation is done, and the available beds in the wards. Available collaboration in healthcare improves the outcomes of the patient like reduction of acute drug reactions, reduction of morbidity and mortality rates, and optimizing medication doses (Bosch et al, 2015, par.1) Blood donations, and prepared medical products constitute other resources to improve health condition of a patient.


The health history of a person shows detailed clinical information. The information is obtained by interviewing the sick person or carrying out the medical examinations to assess their health status. The health history of a person makes it easy for a patient to get a quick and accurate diagnosis of any kind of illness.


Cherry, K., 2021. Erik Erikson’s Stages of Psychosocial Development. [online] Available at: <> [Accessed 25 May 2022].

Singh, N. and Singh, S., 2001. Developmental Considerations in Treatment. Handbook of Conceptualization and Treatment of Child Psychopathology, pp.9-38.

Bosch, B. and Mansell, H., 2015. Interprofessional collaboration in health care. Canadian Pharmacists Journal / Revue des Pharmaciens du Canada, [online] 148(4), pp.176-179. Available at: <> [Accessed 26 May 2022].


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