Health Assessment History

The patient is a 35 years old married African American female named MG. The interview took place on 01/07/2020 at 1200 hours.  The patient is alert, oriented and a good historian. Patient skin is elastic, intact, color normal warm and for ethnicity. Patient facial features are symmetrical, and there appears to be no sign of acute distress. The patients define health as having no physical, mental or psychological issues and feel that apart from the pain that she commonly experiences when active doing home chores and walking around but is relieved when at rest, she is healthy. Her short-terms health goals are to identify the cause of the chest pain on her right side that has been ongoing for two days and gets it treated and lead a normal life in the long run.

Patient denies any unintentional recent weight loss/weight gain, currently not dieting, no appetite change, no allergies, no special diet, does not use any food / herbal supplements, no usage of weight regulatory drugs, denies having eating disorders, no experiences of fatigue and no obvious change in skin or mucous membranes. The Patient has a surgical history of caesarean section without any complication in 2017. Patient denies any other inpatient hospitalization but has a history of sprained left ankle twice in 2013 and 2014 respectively which resolved without treatment. Patient reports that she has only been pregnant once never had an abortion or miscarriage and has only one living kid. Patient refutes having any infantile serious or chronic illnesses. She states that her immunizations are up to date and her only repetitive medication is vitamin B12. Her Paternal grandfather had type 2 diabetes, hypertension, kidney disease but denies any family history of drug addiction, allergies, alcohol, arthritis, asthma, blood disorders, cancer, coronary health disease, obesity, seizure disorder, mental illness, sickle cell anemia, suicide, stroke, and tuberculosis.

Based on Piaget’s theory, the patient is in the formal operational stage of cognitive development and has the ability to think logically as well as abstract reasoning (Carpendale, Lewis & Müller, 2019). The patient can reason about hypothetical situations and plan for the future. Based on Erickson’s theory, MG is at the middle-aged adult stage of psychosocial development and family, and career are the most important aspects of her life (Malone et al., 2016). The patient is working to establish stability in her family as well as make a difference in the society she lives in No major life changes have occurred to her so far.

The patient is a Christian and follows the beliefs of life after death. Her faith does not enforce any dietary and medical procedures restrictions, and she is open to any form of treatment. The patient has an associate degree and currently a full-time student. The patient is hard-working and goal-oriented. She exercises routinely, eats healthy and no problem with elimination. The patient has good sleep hygiene practice. Patient reports that she has a good interpersonal relationship, with leisure activities such as watching movies, going to church and hanging out with friends and family and denies any drug-related or marital problems. The patient states that she is satisfied with her state of wellness and health practices.  Her family is collaborative and offers both financial and emotional help, and this has greatly contributed to her well-being. She has access to healthcare from the national health system.

Reflection

A medical history interview is significant as a therapeutic and diagnostic tool. The medical history interview with MG was informative and interesting. The patient was especially open with linear thoughts, good eye contact and very alert and oriented to person, place, time and situation. While answering questions, the patient maintained a regular audible speech and a straight face. She did not hesitate in answering any question both personal and family-related. The patient was friendly and establishing rapport was easy. She was, however, haste in answering any drug-related issues. Generally, the patient was talkative and willing to provide as much as possible, and I had to cut her short when she got out of topic.

What I leant and definitely will replicate next time is that establishing a rapport before anything else is significant for successful medical history interviews. The ability to connect with the patient eases the environment enabling the patient to be open. It is common for patients to withhold some information for any reasons, and this hinders the provision of patient-centered care. Good rapport also establishes good communication tendencies in the rest process of care provision. As a health provider, however, building rapport is based much on one’s communication skills (Lang, 2012). Patients are different and require to be approached differently. Good communication skills not only help in the accurate diagnosis but also in overall patient satisfaction, compliance to treatment and building trust (Al Ali & Elzubair, 2016). I hold no regrets concerning the interview and look forward to more interviews to be able to provide patient-centered care.

References

Al Ali, A. A., & Elzubair, A. G. (2016). Establishing rapport: physicians’ practice and attendees’ satisfaction at a primary health care center, Dammam, Saudi Arabia, 2013. Journal of Family & Community Medicine, 23(1), 12.

Carpendale, J. I., Lewis, C., & Müller, U. (2019). Piaget’s Theory. The Encyclopedia of Child and Adolescent Development, 1-11.

Lang, E. V. (2012). A better patient experience through better communication. Journal of radiology nursing, 31(4), 114-119.

Malone, J. C., Liu, S. R., Vaillant, G. E., Rentz, D. M., & Waldinger, R. J. (2016). Midlife Eriksonian psychosocial development: Setting the stage for late-life cognitive and emotional health. Developmental psychology, 52(3), 496.