A Survey Health History Assessment On A Patient Represented By The Initials

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Introduction Every patient that comes in seeking medical attention, has had a health history assessment conducted on them. Such an assessment provides health care workers such nurses, with vital information about the patient’s overall well-being. It can also be viewed as a guide in directing the nurse, in provided the most beneficial and utmost plan of care. The purpose of this paper is to exemplify a conducted health history assessment on a patient represented by the initials L.H.; Which focuses on subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings. Demographic Data Patient L.H. is a 69-year-old married Caucasian male that is a retired teacher that lives at home with his…show more content…
Family Medical History L.H. is the youngest child, by his deceased parents. His father died of a heart attack at the age of 62; while his mother passed away at 88 years old from chronic leukemia. L.H brother is alive and well. Currently, L.H wife is current 68 and is healthy, with the same for their son who, is 40 years old. Review of the Systems The general health of the patient is currently being compromised due to present illness mentioned above, but is stable. L.H. reports his usual health to be, “normal and not too crazy like this”. Patient has some fatigue noted while conducting daily activities; No recent weight change, fever or sweat. The skin noted to some discoloration on upper right side of back. There is no pruritus, rash or lesions present. Bruises noted bilateral on arms. Patient reported taking baby aspirin as daily medication. His hair is greying and thinning with no hair loss. L.H. report no concurrent or severe headaches; There was no head trauma, syncope or vertigo. Patient wears corrective lens with no difficulty of vision or diplopia; absent of inflammation, discharge or lesion. Last eye exam was in September of 2016 with no history of glaucoma, cataracts. L.H. denies having any frequent colds, sinusitis, epistaxis and trauma. Patient reports having obstruction stating, “it happens when I am lying down” with an occasional postnasal drip. The patients mouth and throat are absent of any pain,

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