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Health History of a Patient

Introduction

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.

Demographics

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
1Age74 years old
2Marital StatusSingle but lives with a family
3RaceBlack African-American
4GenderFemale
5Religious preferenceChristian
6Height62 inches
7Weight229 kgs
8Reason for seeking careComplete 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 ConditionHistory of Health Condition
1HTN
2Morbid Obesity
3Osteoarthritis (OSA)
4Impaired Fasting Glucose (IFG)
5Dyslipidemia
6Chronic Hyperkalemia
7Chronic Pain Syndrome
8Upper Respiratory Allergy
9Acute 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.

Medications
Drug Amount
1Losartan-hydroCHROthazide100mg-250mg
2Labetalol100mg
3Atorvastatin40mg
4Amlodipine5mg
5Fluticasone50mcg/inch
6Nasal spray
7Allociterol
8Cetirizine10mg
9Famotidine20mg
10Montelukast10mg

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 
StagePsychosocial CrisisWhat happened to the patientMet/Not Met
1Trust vs MistrustDevelopment of a sense of trust
2Autonomy vs ShameDo things independently or doubt abilities
3Initiative vs GuiltInitiate plans or feel guilty about efforts
4Industry vs InferiorityA pleasure to apply to tasks or feel inferior
5Identity vs ConfusionRole testing or confused about who they are
6Intimacy vs IsolationForm close relationships or feel isolated
7Generativity vs StagnationContributing to society or lack of purpose
8Integrity vs DespairSense 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.

Conclusion

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.

References

Cherry, K., 2021. Erik Erikson’s Stages of Psychosocial Development. [online] Available at: <https://www.verywellmind.com/erik-eriksons-stages-of-psychosocial-development-2795740> [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. https://www.researchgate.net/publication/289518543_Developmental_Considerations_in_Treatment

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: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530359/> [Accessed 26 May 2022].

 

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