Patient Health History Taking
BIOGRAPHICAL DATA:
Name:
Address:
Birthdate:
Birth place:
Phone:
Religion:
Sex:
Marital
... [Show More] status:
Educational level: Occupation:
Significant others or support persons:
Date of interview:
CHIEF COMPLAINT:
The clients’ reason for seeking health care is due to hypertension causing the elevation of her blood pressure.
HISTORY OF PRESENT HEALTH CONCERN:
Mrs. Maaro is a 50 years old office employee who seek healthcare due to hypertension. In relation to this, she stated that prior in this interview it was the same since it began that she feels dizzy accompanied with headache behind her eyes. She detailed that the dizziness lasts for few hours then stops. The pain was on the scale of 7 and described as the worst pain experienced. Moreover, the client mentioned that her concern regarding dizziness becomes better when she try to relax and rest lying down but contrary to that, the feeling becomes worse when she try to move around.
PAST HEALTH HISTORY:
Regarding to the clients’ past health history, Mrs. Maaro mentioned that her immunization up to now is the flu vaccine. Additionally, with regard to her health history, she inform us that she underwent a surgery last 2015 and 2018 wherein, the 2015 surgery was about the removal of a lump on the breast and the surgery last 2018 was about tubal ligation.
FAMILY HEALTH HISTORY:
The clients’ parents are both deceased. During their living, her parents’ health concern of illnesses was about hypertension. Also, the client mentioned that her aunt’s and uncle’s illnesses were hypertension, cancer, and diabetes. While on the clients’ children illness is asthma.
ENVIRONMENTAL HISTORY:
In relation to the clients’ environmental history, she state that she is able to perform her duties and tasks on daily basis but sometimes her hypertension restricts her to do so. The client also stated that she is fond of planting on their garden additionally, the client states that she is not following any diet with no report to exposure with infections.
Current Health History:
In this part, Mrs. Maaro mentioned that she is currently taking a losartan medication prescribed by her doctor. Another current health history she mentioned was the symptoms she feels such as headaches and dizziness with no improvement or aggravate.
PSYCHOSOCIAL HISTORY:
Regarding the clients' psychosocial history, she gets along well with her family. She enjoys gardening and watching dramas as her form of leisure activity. She also stated that, with the profession that she has, she doesn't feel too much anxiousness, nervousness, or stress in social situations. Common stressors in her workplace and financial problems are her stressors in life.
REVIEW OF SYSTEM:
In the clients' review of systems (general), she usually sleeps for 5-6 hours a day, and regarding her weight, she gained 2 kilos recently. She's not experiencing fatigue, fever, chills, and night sweats.
NUTRITIONAL HEALTH HISTORY:
Regarding the clients’ nutritional health history, she eats three meals a day and usually eats at home and school. If available, she eats about three pieces of fruit, depending on what is available. Water is her usual drink, but she also drinks sodas and juice if available. She also mentioned/stated that 2-3 times a week she eats red meat or pork and chicken, 3-4 times a week she eats fish and every after a meal there is a dessert or sweets.
ASSESSMENT OF INTERPERSONAL FACTORS:
In this part regarding the clients’ interpersonal factors, she have friends and associates in life but only few whom she considered being close with her. She’s also not bothered with feeling of anxiety or discomfort around others. Also, she mentioned that people around her, especially her family supports her in everything that makes her happy and always reminding her to take care of herself. She has a positive feeling towards her relationships [Show Less]