A health history is an essential tool in the assessment process, allowing healthcare professionals to obtain crucial information about an individual’s health status. This assignment involves conducting a health history on a family member or friend, with their consent, using the interviewing techniques learned in Module 2. The purpose of this task is to gather information on the individual’s medical history, lifestyle factors, and current health concerns. This paper summarizes the health history information gathered and addresses specific questions related to the assignment.
Health History Summary:
The individual for this health history assignment is a family member, Mr. X. He gave his consent and agreed to disclose his medical information for educational purposes. Mr. X is a 45-year-old male of African American descent, married with two children. He works as a software engineer and leads a sedentary lifestyle due to the nature of his work. The interview was conducted in a comfortable and private setting to ensure confidentiality and openness during the process.
In gathering the medical history, various aspects were explored. Mr. X reported having suffered from hypertension for the past seven years, which is being managed with antihypertensive medication. He has a family history of cardiovascular disease, with his father and grandfather experiencing heart attacks in their 50s. Mr. X also revealed a history of seasonal allergies, for which he takes over-the-counter antihistamines as needed. Furthermore, he reported a surgical history of an appendectomy at the age of 28, with no complications post-surgery.
Mr. X currently takes prescribed medication for his hypertension, namely lisinopril, 20 mg daily. He ensures regular compliance with his medication regimen and monitors his blood pressure at home. Additionally, he occasionally uses over-the-counter antihistamines for allergy symptoms during seasonal changes.
Regarding immunizations, Mr. X reported receiving routine vaccinations during childhood, including measles, mumps, rubella, and varicella. He confirmed receiving the flu vaccine annually since the age of 35, as recommended by his primary care physician. However, he mentioned that he has not received any other vaccines, such as the pneumococcal or hepatitis vaccines.
Current Health Concerns:
During the interview, Mr. X expressed concerns about his weight and sedentary lifestyle. He reported gradual weight gain over the past few years, which he attributes to his desk job and lack of physical activity. He expressed a desire to lose weight and improve his overall fitness level to decrease his risk of chronic diseases. Additionally, he mentioned occasional sleep disturbances, which he believes are associated with job-related stress.
Exploring Mr. X’s lifestyle factors provided valuable insights. He acknowledged having a sedentary job that involves sitting for long periods, with limited opportunities for physical activity. He expressed a preference for home-cooked meals, primarily consisting of carbohydrates and processed foods due to time constraints. Mr. X also admitted occasional indulgence in fast food, especially during busy workdays. Furthermore, he revealed that alcohol consumption is limited to social occasions and occurs approximately 2-3 times a month, with an average of 2 drinks per occasion.
Family Medical History:
Mr. X shared information about his family’s medical history, which indicated a strong genetic predisposition to cardiovascular disease. His father experienced a heart attack at the age of 58 and subsequently underwent bypass surgery. Additionally, his paternal grandfather died of a heart attack in his early 50s. Mr. X’s mother has a history of osteoarthritis, and his maternal grandmother had type 2 diabetes.
During the interview, Mr. X described his job as demanding but fulfilling. However, he expressed occasional work-related stress, which he manages through exercise and spending quality time with his family. He stated that he receives great support from his spouse, who helps him navigate stressful situations effectively. Mr. X also mentioned being involved in community service activities, which he finds mentally and emotionally rewarding.
This health history assignment provided valuable insights into the medical history, lifestyle factors, and current health concerns of Mr. X. His history of hypertension, family history of cardiovascular disease, sedentary lifestyle, and weight gain are significant concerns that require attention. Further health promotion and education can be targeted towards modifying his lifestyle choices, such as incorporating regular exercise, adopting a balanced diet, and managing stress effectively.