Health History for Health Assessment Essay

3959 Words Sep 29th, 2011 16 Pages
NSG306 Health Assessment:
Health History on Mr. Ricky Ricardo
Jean Bors-Koefoed & Sarah Wright
Baptist College of Health Sciences

Health History
Biographical Data
Date: 05-23-2010
Name: Ricky Ricardo
Gender: Male
Race/Ethnicity: Hispanic
Marital Status: Married
Date of Birth: XX/XX/XX
Occupation: Medical Device Representative
Address: XXX XXXX
Phone Number: (XXX) XXX-XXXX
Contact Person (relationship to patient): Lucille Ball/wife (XXX) XXX-XXXX
Reason for Seeking Healthcare:
“Providing a Health History for Health Assessment”

History of Present Illness:
Patient does not have a present illness. He is only seeking care for the purpose of providing a health
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Should he experience another infection similar to one typically caused by Staph, understanding that he has had a Staph infection in the past can help physicians make an accurate diagnosis quickly and treat the infection accordingly.

Hospitalizations: The patient was hospitalized in 1984 for two weeks for Osteomyelitis. He had to undergo surgery to remove the infection in the proximal portion of his left tibia..
Hospitalizations in the past can give insight to a current or pre-existing condition. The specifics of a hospitalization make it easier to receive the medical records if necessary. It is also important to record any psychological hospitalizations because they can also give explanation to current health issues. With just the one hospitalization in his health history, the Mr. Ricardo is unlikely to have any residual problems resulting from his stay.
Immunizations: The patient is up-to-date on all immunizations. According to the patient’s health records from the Pennsylvania Department of Health, he received the last of five Diphtheria-Tetanus-Pertussis on November 3, 1980. He also received just a Tetnus-Diptheria vaccination on October 23, 1990. He had the final dose of the three Oral Polio immunization on January 30, 1979. He had both his Rubella and his Mumps vaccines on September

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