Health History Interview and Risk Assessment
Student Name
MSN 572: Physical Assessment Across the Lifespan A
United States University
Professor Name
Submission Date
Subjective
ID: HH, Date of Birth: 05/25/1958, Age: 65, Gender: Male, Race: Caucasian, Reliable Historian.
CC: “I am here for my annual check-up.”
HPI
Haq, a 65-year-old Asian male, presents for his annual wellness visit. He is a healthcare worker with a background in nursing. Haq mentions that his last physical was conducted on 06/15/2021. His last cholesterol screening was done on 07/01/2021 and showed normal results. Haq reports no history of colonoscopy. He currently complains of occasional joint pain in his knees and shoulders. The joint pain started about a year ago (09/01/2022) and is described as a dull ache that worsens with prolonged standing or activity. He rates the pain as 5/10 on the pain scale. Haq reports using over-the-counter pain relievers like acetaminophen for relief. No other complaints are noted at this time.
PMH
- Medical Problems: Hypertension, controlled with medication.
- Surgeries and Hospitalizations: Haq had a hernia repair surgery in 2010.
- Immunizations: Haq receives his annual flu vaccine. He also had the pneumonia vaccine administered in 2019.
- Allergies: No known allergies to food, drugs, or environmental factors.
- Medications: Lisinopril 20mg daily for hypertension.
Family History
- Mother (MGM): Deceased at age 75 (passed away in 2005 due to complications from diabetes).
- Father (FGF): Alive, age 90, with a history of hypertension.
- Siblings: Haq has one older sister, age 68, who has a history of osteoporosis.
- Children: Haq has one adult son, age 35, who is in good health.
Chemicals
- Alcohol: Occasional social drinking, 1-2 drinks per month.
- Tobacco/Nicotine: Non-smoker, no history of tobacco use.
- Drugs: No history of recreational drug use.
Diet/Exercise
- Diet: Balanced diet with regular intake of fruits, vegetables, and lean proteins. Occasional fast food, once a month.
- Exercise: Haq engages in daily 30-minute brisk walks and practices light yoga.
Sexual/Reproductive History
- LMP: Not applicable (male).
- Contraception/Protection: Not applicable (male).
Social History
- Occupation: Healthcare worker specializing in nursing.
- Marital/Relationship Status: Married for 40 years.
- Military Status: Not applicable.
- Current Living Situation: Owns a house in a suburban neighborhood.
Spiritual/Social Supports
- Haq identifies as Muslim and regularly attends the local mosque. He is an active member of his community.
Safety
- Haq wears seatbelts while driving. No firearms in the household. No history of domestic violence/partner violence.
ADLs/IADLs/AADLs
- Haq is fully independent in activities of daily living.
Review of Systems
- Constitutional: No fever, chills, or unintentional weight loss reported.
- Eyes: No visual disturbances, eye pain, or vision changes.
- Ears, Nose, Throat: No hearing loss, tinnitus, sinus congestion, or sore throat reported.
- Cardiovascular: No chest pain, palpitations, or shortness of breath with exertion.
- Respiratory: No cough, wheezing, or shortness of breath at rest or with activity.
- Gastrointestinal: No abdominal pain, nausea, vomiting, or changes in bowel habits.
- Genitourinary: No urinary frequency, urgency, dysuria, or hematuria reported.
- Musculoskeletal: No joint pain, stiffness, or muscle weakness reported.
- Integumentary/Breast: No skin changes, lesions, or breast abnormalities noted.
- Neurologic: No headaches, dizziness, syncope, or focal neurologic deficits reported.
- Psychiatric: No symptoms of depression, anxiety, or mood disorders reported.
- Hematologic/Lymphatic: No history of bleeding disorders or lymphadenopathy reported.
- Endocrine: No symptoms of thyroid dysfunction or diabetes reported.
- Allergic/Immunologic: No known allergies or history of immunodeficiency reported.
Assessment
- Risk of Hypertension (HTN) due to family history and age.
- Rationale: Haq’s family history of hypertension and his age place him at increased risk for developing hypertension. His current medication regimen is effectively managing his blood pressure (Carey et al., 2022).
- Risk of Musculoskeletal Issues due to chronic joint pain.
- Rationale: Haq reports persistent joint pain in his knees and shoulders. Further evaluation may be necessary to determine the underlying cause and appropriate management (Bonanni et al., 2022).
- Routine Health Maintenance: Recommend scheduling a bone density scan to assess bone health and screen for osteoporosis.
- Rationale: Haq’s sister has a history of osteoporosis, indicating a potential familial predisposition. A bone density scan will help evaluate his bone health (McNabb Baltar et al., 2022).
Plan
Diagnostic Plan
- Order bone density scan to assess bone health and screen for osteoporosis.
Therapeutic Plan
- Continue lisinopril 20mg daily for hypertension management.
- Recommend over-the-counter pain relievers for joint pain as needed, with caution for excessive use.
- Provide guidance on joint-friendly exercises and stretches for pain management.
Referrals
- Refer to a rheumatologist for further evaluation and management of joint pain.
Education and Follow-up Plan
- Educate Haq on the importance of regular exercise, maintaining a balanced diet, and monitoring blood pressure.
- Instruct Haq to follow up in 6 months to re-assess blood pressure and joint pain.
Preceptor
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
Bonanni, R., Cariati, I., Tancredi, V., Iundusi, R., Gasbarra, E., & Tarantino, U. (2022). Chronic pain in musculoskeletal diseases: Do you know your enemy? Journal of Clinical Medicine, 11(9), 21–29. https://doi.org/10.3390/jcm11092609
Carey, R. M., Moran, A. E., & Whelton, P. K. (2022). Treatment of hypertension: A review. The Journal of the American Medical Association, 328(18), 1849–1861. https://doi.org/10.1001/jama.2022.19590
McNabb Baltar, J., Manickavasagan, H., Conwell, D. L., Lu, A., Yadav, D., Hart, P., Lara, L. F., Cruz Monserrate, Z., Ing, S., Hinton, A., Mace, T. A., Bradley, D., & Shah, Z. K. (2022). A pilot study to assess opportunistic use of CT-Scan for osteoporosis screening in chronic pancreatitis. Frontiers in Physiology, 13. https://doi.org/10.3389/fphys.2022.866945
