Critique your last physical assessment on the basis of health promotion, health prevention, and comfort for you as the patient. Write a 750–1,000-word paper that addresses the following questions:Did the provider evaluate lifestyle, nutrition, and exercise?Did the provider explain the side effects of your medication?Was there an agreement on the plan of care?What was the environment like? Welcoming, comfortable, dirty, clean?Did the provider answer your questions and perform a complete health history?Was the physical assessment complete and correct? (Did the provider listen to your lung sounds through clothing?)Did the provider see you in your street clothes or in a patient gown?Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is required.
comprehensive_health_history_julie_braylock.docx
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Running head: COMPREHENSIVE PATIENT HISTORY
Comprehensive Patient History
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COMPREHENSIVE PATIENT HISTORY
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Comprehensive Health History
The procedure used to obtain a patient’s history is very important. This procedure must be
effectively applied to ensure all accurate and necessary data is collected from such a patient. There
must be a contrast between this procedure and the arrangement of the health history of a particular
patient. These two aspects are very vital because the patient must fill the specified needs. First of
all, health history conformation is an organized system that is used in the sorting of data from the
patient, it is basically an approach of clinical consideration of all sorts of data that are mandatory
to be collected from the patient before any medical attention (Carroll et.al, 2012). Secondly, the
meeting process is not necessarily for data collection but for evoking the precise data and
interpersonal issues and abilities that can facilitate the service delivery to the patient. In this paper
the whole interviewing procedure will be applied on a friend by the name Stevens. This paper will
try and analyze his comprehensive health history and various techniques that are used to interview
this patient when recording the historical data.
The meeting of medical attendant and the patient is the way in which a doctor can rehearse
his flexibility on duty. The conversation that takes place is very enthusiastic and scholarly. In this
scenario the capabilities of analytical thinking is regulated to favor the present situation of
interpersonal skills of the patient so as to encourage and motivate the patient.
Identifying Data
Stevens is the name of the patient. He is 25 years old of age and is currently working with
Coffee Stack Company. The condition of Stevens is low moods and anxiety which is to be
evaluated.
COMPREHENSIVE PATIENT HISTORY
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History of Present Illness (HPI)
Stevens a 25 years old man is reporting to have encountered problems with anxiety and
moodiness in the good part if his life. He has been treated in the past 7 months, he has received
some guidance and counselling but the situation seems to persist. This condition began when he
broke up with his lover who he says he loved with all his heart. He was in a marriage and breaking
up was very painful indeed. His current symptoms include low appetite, thinking a lot,
hallucinations, decreased energy, feeling unworthy, low self-esteem, and low mood in most of the
days, panic attacks and feeling of high levels of anxiety. This condition has lowered his levels of
concentration whenever he is at work even when he is enjoying the company of friends. He reports
that it has reaches a point that he does not want to live any more, feels not wanted in this life. He
can actually commit suicide in case the condition worsens. Besides, he has worries about his future
relationship with any other lady due to the experience he has passed through. He denies any ritual
which are compulsive or any excessive thinking about it. He has tried to insists on long time dosage
of sertraline 100mg per day to escitalopram10mg (3week trial), paroxetine (2 week trial‐ stopped
due to side effects), and venlafaxine (started on 75mg 2 weeks ago), but none of these medicine
changes have had a significant change in his mood and anxiety. He is becoming more hopeless
and wondering what to do next, and reports of having a feeling of overwhelm with despondence
as does not see if he can join any marriage strong as this was.
Past Medical History
The patient has been occasionally experiencing migraine headaches. He has never been
hospitalized, he has never encountered any surgery as far as his health condition is concerned. The
COMPREHENSIVE PATIENT HISTORY
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patient is not allergic to any condition or to any drug. The current physician of Mr. Stevens is Don
Marcella. He is under the medication of Venlafaxine.
Family and Medical History
The paternal grandfather of Stevens used to suffer from depression and hallucinations. He
reports that his parents are both in good health condition and are not experiencing any similar
condition. He does not believe that is any psychiatric problem with his father although is not such
sure of this. The only condition that her mother faces is overweight. All his siblings are in good
health and not in any complication.
Review of Systems
GENERAL: Some fine tremors noted as well as nervousness
RESPIRATORY: Patient denies SOB
CARDIAC: Denies Chest Pain
GASTROINTESTINAL: No nausea or vomiting, denies difficulty eating and no diarrhea.
GENITOURINARY: Denies any problems urinating, denies changes of frequency, color
or character of urine.
MUSCULOSKELETAL: Denies any changes in gait or range of motion of extremities.
NEUROLOGIC: States he has some dizziness and generalized weakness denies a headache
and feelings of confusion
INTEGUMENT: Denies any rashes or color of skin changes.
COMPREHENSIVE PATIENT HISTORY
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Assessment
Stevens is 25 years old man and is complaining a lot about social anxiety which has come
to impact her life negatively. This has disturbed his social approach and occupational life in
general. The degree of this social anxiety has gone to higher levels and turned chronic. Currently,
he is very depressive over the past 7 months, up to the moment he has tried several medications
but still no change is obtained and only he has one chance of medication.
Outpatient treatment is the best for Stevens because he is not in a suicidal condition and
not psychotic. However, increased amount of Venlafaxine although it has its side effects like
insomnia, nausea and increase in blood pressure (Anandarajah and Hight, 2001). In addition, I will
recommend Lorazpam for sleeping problems. This drug is recommended because it does not have
addiction. Thirdly, cancelling is very necessary in this situation from a psychotherapist who will
help in augmenting the cognitive behavior and reducing of the anxiety.
Conclusion
The history of the patient should be recorded in a very critical and procedural manner. The
interviewing process must follow a procedure. This will ensure that the doctor is able to collect
the required data from the patient and promoting inter-personal relations. The doctor must possess
abilities like compassionate, sympathy and considerate in order to attain correspondence. The
environment for interview must be confidential and secret to the patient. This methodology
encourages extensive patient history.
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References
Anandarajah, G., & Hight, E. (2001). Spirituality and medical practice. American family physician,
63(1), 81-88.
Carroll, J. G., Frankel, R. M., Keller, A., Klein, T., & Williams, P. K. (2012). The medical
interview: clinical care, education, and research. S. M. Putnam, & A. Lazare (Eds.).
Springer Science & Business Media.
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