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?
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Running head: COMPREHENSIVE HEALTH ASSESSMENT
Comprehensive Health Assessment
Christina Graham
Grand Canyon University
Advanced Health Assessment for Nurse Educators
NUR – 645
August 18, 2016
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COMPREHENSIVE HEALTH ASSESSMENT
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Comprehensive Health Assessment
Identifying Information
Name Tommy Luscious
D.O.B: 3/7/ 1977
Age: 38 years
Date: 7/9/2016
Tommy Luscious is a middle-aged male of average height and sees with the aid of glasses. He
resides in Brooklyn in New York. He is a banker by profession and works for the New York
state bank. He is married and a father of two girls aged 9 and 13.
Past Medical History
When Tommy was aged 14, he was hospitalized with tuberculosis and spent sixteen weeks in the
hospital. He was however discharged and has not had anything disturbing for quite some time
(Bickley & Szilagyi, 2012). At 27, he started experiencing recurrent back pains that his doctor
associated with inappropriate sitting position. As such, he was prescribed to occasion ibuprofen.
Tommy reports that the back pains have subsided since the adjustments of the sitting position.
For the last three months, luscious explains that he has been treated with typhoid twice and
malaria once. However, the symptom never goes completely despite visiting a different clinic
every time he falls ill. As such, he is of the opinion that he has been misdiagnosed since the
symptoms keep recurring.
Health Status, Perceived Barriers, and Support
Tommy is currently not of good health, and the symptoms are making it impossible for him to
carry out a normal life.
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Tommy reports that the fact he has been treated twice for typhoid has made him loose hope and
therefore become tired of seeking the help. More so, he says that he feels financially constrained
and does not want to waste more money for treatment that keeps recurring. When I ask for his
health insurance, he says that he is currently not subscribed to any (Bickley & Szilagyi, 2012).
Another thing that makes him avoid hospital visits are the many sick leaves he has had to take
and hence to risk his job.
When I ask about support, he says that he lacks medical advice from his previous caregivers and
therefore become demotivated. However, he states that his two girls and his wife who is waiting
for him outside my office are of great support to him. As such, they are the reason why he has
decided to seek lasting medical solution (Bickley & Szilagyi, 2012).
Chief Complaint
According to Tommy, the main complaints include vomiting. He describes it as the most
discomfort that is making his live unbearable. As such, he goes without eating solid food most of
the time. He goes on to narrate how he had to skip supper and breakfast to manage this interview.
He also reported experiencing severe headaches that are accompanied by fever (Bickley &
Szilagyi, 2012). He has been forced to rely on pain relievers to minimize the headaches that keep
him awake almost every night.
History of Current Illness
The current illness started as fever with an occasional headache which Tommy dismissed
attributing them to the busy schedule at work. As such, he just used pain relievers. The
symptoms became worse, and when Tommy started vomiting, he decided to seek medical help,
and that is when he was diagnosed with malaria three weeks ago (Bickley & Szilagyi, 2012).
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Without knowing it is the progress of the symptoms, Tommy associated the neck stiffness and
drowsiness to the medication that he was using. As such, he continued to take the meds without
being alarmed.
Social History
Tommy is the sociable person making friends from the work place to the church. He, therefore,
participates a lot in church activities. When he hangs out with friends, he takes a beer or two, but
he does not smoke. Being a banker his movements in the office are limited and therefore is
seated most of the time (Bickley & Szilagyi, 2012). Due to his career and family demands, he
does not travel a lot. He loves the gym, but sometimes cannot afford it. However, he goes or a
run with his wife every morning.
Focused Review of Systems
From the analysis, the constitutional symptoms include weight loss and sleeping disorder
attributed to the vomiting and headaches. For the eyes, Tommy indicated that he had not
experienced any changes since the onset of symptoms (Bickley & Szilagyi, 2012). As with the
nose mouth and throat, there is no pain emanating from these areas. In addition, he has not had
any problems with his heart as well as his respiratory system. However, the severe vomiting has
really affected his gastrointestinal and hence swallowing has become difficult. He has not any
problems with his genitourinary tract except for reduced passage of urine. He, however,
experience neck stiffness for no reason as well as unexplained muscle pains especially the neck
region and upper back (Bickley & Szilagyi, 2012). The psychiatric problems include irritability
and confusion. As well, the neurological disorder is the occasional seizures that have occurred
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twice in two weeks. Problems associated with the endocrine system include cold hands and legs.
However, he has not experienced any bleeding or allergic reactions.
Variables to Consider
The age variables that were considered are the date of birth and number of years, while religious
variables include Christianity and Islamic as well as his believe in God (Bickley & Szilagyi,
2012). Cultural beliefs and practices such as their belief in what causes illnesses and what they
do hence the get sick were also considered. These variables guided me on the questions to ask on
every aspect of the history. The considerations of these variables are meant to keep the patient at
ease for them to open up. For instance, when getting their perceived barriers, it is good to
consider the cultural beliefs in medicine.
Eliciting Patient’s Interpretation
To get the patient’s perspective about their health status one can ask about the patient’s thoughts
about the problem as well as their fears and how they feel about the illness (Stewart, 2011). To
get information on the perceived barriers and support a clinician should include the patient’s
expectations of them and people close to the patient. To achieve this, the clinician can ask
questions that do not imply that the patient is being asked to outline their weaknesses. As such,
the physician should employ the use of indirect language. For instance, instead of asking a
patient whether money is the reason why they did not seek medical help earlier one can ask them
about their health insurance and the money they have incurred to get medical care. As such, the
patient will open up and talk about their finances (Stewart, 2011). To get patients talk about their
support one can enquire about their personal relationships or family. This line of questioning will
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not have the patient suspect what you are asking and therefore the temptations t lie will be
avoided. By the kind of responses that the patient gives it is easy to get the patients perspective.
History Taking Techniques
Clinicians apply different techniques when gathering information from a patient. For instance,
active listening is a technique that involves listening carefully with minimal or no interruption
(Stewart, 2011). However, its effectiveness is based on the listener’s ability to listen without the
temptation to drift away and start thinking about other things. As such if the listener should have
wander in thought this technique will not be effective. The other technique is the guided
questioning that aids the patient to give consequential information without distortion. The
technique is only effective with people who listen without formulating on what question to ask
next. Therefore, if the clinician keeps thinking about what question to ask next instead of
listening to the answers, the method will not be effective (Stewart, 2011).
Finally yet importantly, is the empathic technique which in which the clinician shows
understanding to the patient’s problems. It is, therefore, important for clinicians to keep
sympathy at bay. This is because it is easy for empathy to turn into sympathy. As such the patient
will feel even more desperate and hopeless incase, empathy becomes sympathy. However if well
utilized the empathy technique is very effective because enhances the connectedness between the
patient and the clinician and hence a relationship (Stewart, 2011).
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References
Bickley, L., & Szilagyi, P. G. (2012). Bates’ guide to physical examination and history-taking.
Lippincott Williams & Wilkins.
Stewart, M. A. (2011). Effective physician-patient communication and health outcomes: a
review. CMAJ: Canadian Medical Association Journal, 152(9), 1423.
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