Health History for Health Assessment

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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 history for the interviewer’s assignment. Obtaining the history of the presenting illness of a patient is important in determining if the illness is a one-time acute condition, or one of a more chronic nature. If the patient has experienced the same illness or symptoms in the past, it can be helpful to know how the condition was treated and how successful the treatment was, so a current course of therapy can be prescribed effectively. In the case of Mr. Ricardo, because he does not have an illness at the present time, he would not have a history of an illness to provide. Current Health Status:

Medications (prescribed/over-the-counter): The patient is prescribed Adderral for ADHD. Patient takes 30mg/2x a day. Last dose taken was May 18, 2010. Patient also takes Benadryl when needed. Medications are important to document because they can sometimes be the cause of what is wrong. Prescribed drugs and over-the-counter drugs can interact with each other and have negative consequences. It is also important to consider dosage of each medication because the dose itself might need to be adjusted because it is causing problems. For this patient, this information can be significant because Adderral has various side-effects that can affect other aspects of the patients’ life, such as depression of his appetite, or hindering his normal sleeping patterns. Upon further investigation, Mr. Ricardo did mention “occasional problems falling asleep”, which could be the result of the side effects from his medication. Allergies (meds, food, environmental, medical products): The patient is allergic to cats and has seasonal allergies. When the patient comes in contact with a cat, he breaks out in hives and has a runny nose. His seasonal allergies cause a runny nose, sneezing, and itchy, watery eyes. History of allergies may explain current problems or give insight as to what could be adding to the problem. It can also prevent life-threatening situations. For example, if the patient was allergic to penicillin they could have a severe allergic reaction that could possibly result in death. This is why it is important to know what the patient is and is not allergic to. While the patient interviewed did not have any severe allergies to medications or food, his seasonal allergies are important to note, should he ever present with symptoms commonly associated with his allergies, so he can be properly diagnosed. Past Health History:

Childhood Illnesses: As a child, the patient had Influenza, chickenpox, throat infections, and Osteomyelitis. While the patient was unable to remember the exact dates he had experienced the flu as a child, he had the chickenpox for approximately one week in the summer of 1985, and was inflicted with osteomyelitis in October of 1984. He remembers several bouts with strep throat throughout his childhood, though he is unsure of the quantity or timings of the disease. Mr. Ricardo hasn’t had any complications in later years due to throat infections. Childhood illnesses can have a direct influence on a person’s current health condition. A history of one illness as child might explain later illnesses in adulthood. For example, childhood chickenpox, as this patient has...
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