NURS 6512 Discussion: Building a Health History Example Solution

The scenario I was given for this week is an 80-year-old white male with angina who lives on a farm 80 miles from a healthcare center. 

According to the National Institute on Aging (NIA), 25% of seniors aged 65 to 70 have hearing loss, while 50% of those over 75 have debilitating hearing loss. Talking clearly and slowly, looking at the patient directly, and reducing background noise are all ways of dealing with hearing loss (National Institute on Aging, n.d.-b). 

Background noise could distract patients from listening to what you are trying to communicate with the patient. Sit facing the patient, employ active listening techniques, ask open-ended questions that might elicit a more thorough response, inquire about their functional status, and, if possible, request medical records from another provider before the appointment so that you can gather additional information that the patient may not provide to obtain an accurate medical history via interview (National Institute on Aging, n.d.-a).

When there is excellent communication between the practitioner and the patient, health assessment questions can be answered to the best of one’s ability. For the patient to grasp what you are asking or saying, the National Institute on Aging (n.d.-b) advises avoiding medical terms and adopting straightforward language and expressions. 

The cardiovascular risk calculator from the ACC/AHA is the risk assessment tool I selected to employ for this patient. The patient’s angina complaint was why I decided on this tool. To ascertain the likelihood of a stroke, heart attack, or death from cardiovascular illness within the next ten years, persons should have a cardiovascular risk assessment (UpToDate, n.d.). To use this tool efficiently, this patient would require simple laboratory tests to determine his total cholesterol and HDL cholesterol. His medical history for diabetes, the drugs he is on now, his social history for smoking, and his current medications would all need to be evaluated by the healthcare professional (UpToDate, n.d.). 

Age, race, and gender of the patient are all potential health hazards that should be taken into account. According to the Centers for Disease Control and Prevention, approximately 1 in every 4 American male fatalities are attributable to heart disease in 2021, and 7.7% of white males, or 1 in 13, had coronary artery disease. Diabetes history, a poor diet, being overweight, being inactive physically, and drinking too much alcohol are all potential risk factors for heart disease (Centers for Disease Control and Prevention, 2021). When beginning new drug management, this information should be carefully reviewed and may be obtained during the patient interview. 

A few questions I would ask the patient are:  

• What medications are you now taking? Can I see them, please? 
• What do you consume in the morning? Lunch? Dinner?
• Do you have any dietary or medicine allergies? What responses did you get? 
• Do you find it easy to stand up and move around or feel out of breath?
• Do you experience breathing issues while lying on your back? 
• Any issues using the restroom? 
• Are there any aches or weakened muscles?
• How does this pain feel when it is present? Does it extend to your arm, neck, or jaw? 
• Does it hurt or feel like someone is stabbing you? 
• How long does this discomfort linger before it stops? 
• Is there anything you do that affects it positively or negatively?
• Do you consume alcohol, illegal substances, or smoke?
• What procedures have you previously undergone? 
• How do you feel today?
• Do you get enough rest at night?

NURS 6512 Discussion: Building a Health History References 

Ball, J., Dains, J., Flynn, J., Soloman, B., & Stewart, R. (2021). Seidel’s guide to physical examination 9th edition 2018 (9th ed.). Elsevier. Order a similar paper