Patients Health History Assessment – Health System Example

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"Patients Health History Assessment" is an exceptional example of a paper on the health system. The health assessment data was collected on a neighbor and personal friend. This assessment was performed with the aim of evaluating the health status of the individual. In this assessment, factors such as the person’ s past medical history, family medical history, and psychological considerations were evaluated. Finally, the paper will give an overall reflection of the experience of interacting with the individual. Demographic Data The person examined was a 56-year-old African American male. He is an American national, and a father of four.

He has previously worked and lived in three other countries in Africa. Currently, he lives with his family in one of America’ s cities. Perception of health During my interview with the individual, it became clear that ‘ healthy’ to him means being able to comfortably carry out daily activities. He however believes that no single person can be 100 percent healthy since, at any given time, one might be suffering from either a known or an unknown condition. However, according to him, for as long as such a condition does not affect one’ s daily operations, then the person is healthy.

Based on his judgment of health, he believes that he is healthy. Asked why he believes so, he said that he has no complication or condition that prevents him from running his daily activities. He however acknowledged that in order to improve his health, it is necessary to regularly see a doctor for a checkup. As it turned out, he had not undergone any form of medical checkup in three years. Past Medical History During his early thirties, he had an operation to remove a bullet from his left thigh.

Although he received treatment, he complained of occasional sharp pains in the affected thigh, especially after strenuous activities. There is no record of chronic disease. He has previously been hospitalized for typhoid and food poisoning. The interviewee has an allergy to beef where rushes appear all over the body after he consumes red meat. He has since stopped eating red meat. Finally, in terms of substance abuse, he confessed that he occasionally smokes cigarettes and takes at least five bottles of beer every week. Family Medical History His paternal grandfather died of diabetes at the age of 85, while the mother and paternal grandmother died of breast cancer.

Last year, his younger brother (aged 40) was diagnosed with prostate cancer and is currently undergoing treatment. He further recalled that his father, partner grandfather, and two of his uncles have all been at one stage of their lives rehabilitated for alcohol abuse. His eldest son aged 33 drinks heavily. From the information given, the interviewee has a risk factor for alcohol abuse as well as cancer.

It is likely that at some point in his life, he may suffer from alcohol abuse-related problems. Review of Systems The interviewee was asked to identify any issues with his body systems. First, when asked about his chest, he complained of occasional pains in the chest cavity, especially at night. He also pointed out that he was having difficulty reading documents at night due to poor sight. Finally, he said that his skin does feel itchy at times, but this was not frequent. However, when asked about the nose, throat heart, and lungs, he said these systems were functioning well. Developmental Considerations Based on Erik Erikson's developmental stages, the interviewee is at the middle adulthood stage (40-60 years).

During my interview with him, he pointed out that he has invested quite sufficiently in his children, but mainly through education. He also showed great dissatisfaction with his achievements in life and complained that he never really achieved what he dreamt to be as a teenager. He however did not point out exactly how he failed to meet his dreams.

These patterns are highlighted by Erikson. Furthermore, just as highlighted by the theorist, one of the expressions of stagnation is obesity. I observed that he appeared to be obese and said that he weighed 87 kg.   Furthermore, just as pointed out by Erikson, the interviewee complained a lot, especially about his wife and his parents. Cultural Considerations During his work assignments in Africa, the interviewee pointed out that he had been introduced to a number of traditional medicines. He claimed that simple ailments such as headaches and stomachaches do not necessarily have to be treated in hospitals and hence use traditionally available medications.

Further, as an African American, he said that it feels uncomfortable to be treated by a female nurse. Psychosocial Considerations When asked whether or not he is feeling stressed, his response was “ Yes. ” He argued that the pressure associated with raising ‘ over 18’ children was too much. When stressed, he goes out with his male friends for a football match and/or a drink. Most of the support comes from friends, as opposed to family members. In terms of religious beliefs, he does not go to church regularly.

  Generally, he does not enjoy life as much as he would have wanted to. Focused Assessment Since he has a habit of smoking and taking alcohol, my priority system to check would be the lungs. Although he has not experienced problems with the lungs yet, the use of the above substances usually affects the lungs. Teaching/learning need priorities First, the interviewee needs to have more information on the dangers of substance abuse and needs to understand how such dangers can be minimized. Secondly, the interviewee has little information on stress management and coping skills. Collaborative Resources From my interview with this individual, it is clear that he has no strong support from the family.

However, being a member of a church, he can get support from the church elders and fellow members. In addition, there are a number of gyms around his home that may assist him to maintain a high level of fitness. Finally, there are many hospitals in his town that may provide the necessary support when it comes to maintaining good health. For instance, he may need to visit a hospital regularly for medical checkups. Reflection The interaction I had with the interviewee brought out some of the concepts learned in the health assessment course.

Particularly, as learned in class, respecting the interviewee’ s background, culture and beliefs became critical during the interview. I realized that the interviewee was somewhat uncomfortable when discussing matters relating to his private life. This can be attributed to his African background since the African culture is characterized by privacy, especially on matters relating to one’ s personal life. One of the things that went well was that a good rapport between me and the interviewee was developed, and this can be attributed to the fact that we knew each other quite well.

There were no tense moments during the interview, and this greatly made the process easy. However, one of the causes of the communication barriers was the use of medical terms the interviewee was not familiar with. To overcome this, I had to use alternative terms or rephrase my statements and questions for easy understanding by the interviewee. The inability to agree on a suitable venue for the interview was the main unanticipated challenge experienced.

Initially, I had planned to carry out the interview in his home, but he later disagreed and demanded that the interview be conducted in a private place away from his home. This meant I incur extra costs since the venue was paid for. Looking back, I believe I needed to obtain more information about his diet and eating habits. In addition, I needed to understand whether or not his daily activities and hobbies expose him to health hazards.

In the future, I will ensure that the interviewee is given notice in advance to plan for the interview. This will give him/her more time to prepare for the interview and obtain necessary documents if needed.


Harder, A. F (2009). The Developmental Stages of Erik Erikson. Learning Place Retrieved from
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