Components and Purpose of Health History Assessment: A Case Study

Running head: HEALTH HISTORY ASSESSMENT 1 Health Assessment Student ’sName Institutional affiliation Date Running head: HEALTH HISTORY ASSESSMENT 2 Introduction This paper is about the purpose, process and components of health history assessment. The main purpose for getting health history from apatient is to obtain subjective data from the patient ’s parents of the patient himself/herself in order to assist the health care team to create agood plan that will help in minimizing chronic health conditions such as COPD or enable the health care team promote health or address acute health problems. The main components of health history assessment include performance of physical examination, communication of the findings and documenting the findings. The documentation of a health history should be specific, clear, accurate, objective, concise and current. In my work, Ihave used apatient with schizophrenia which can be caused by genetic factors and both chemical and structural changes in the brain. (De Picker et al, 2017) My client is a 21 year old man who was on physical therapy after being diagnosed with schizophrenia which is psychiatric disorder. The recreational activities of the patient included playing football, swimming and break dancing. The patient had first developed wrist pain on his right hand and sought medical assistance from a sport medicine physician. The radiographs taken were negative and the patient did not receive any medication. Instead the patient was diagnosed with contusion on the right wrist. The patient then later came to me in ahealth facility complaining of pain in the elbow, wrist, knee, neck, ankle and shoulder. The patient explained to me that the pain on the elbow, wrist and ankle were due to injuries he acquired when playing football. Some of the injuries had no reasonable cause hence there was no possible means of management to fix them. The patient kept complaining of right shoulder pain which was aggravated by activities such as pull ups. The pain was not Running head: HEALTH HISTORY ASSESSMENT 3 alleviated by any position or movement and did not change over the course of the day. Pain on the right shoulder also disturbed sleep whenever he slept on the right shoulder. His right wrist and left knee felt cold at sometimes without any reasonable cause. The patient thought that he felt cold because of electrical implant on his body which he believed was sending electromagnetic impulses to the joint. He also believed that these impulses were the cause of his occasional shoulder pain. The patient believed that the implant denied him his recreational activities and he complained that other people in the society were operating effectively with them without any problems. The patient had been receiving commands to harm his family and friends around him and he believed that he had been receiving these commands from the electrical implant and that is why he distanced himself from his friends. The patient did not use any medication over the past but he thought that his believes about the electrical impulse were alleviated by marijuana he took occasionally and alcohol consumption. The patient did not complain of difficulties in breathing, any weight changes and bladder pains. He was stable while walking and would seat comfortably without any support. Iassessed the patient ’sposture in sagittal and frontal planes and he had forward head posture. After analyzing the sagittal plane, the glen humeral joints were rotated internally. The analysis on the frontal plane showed that his right shoulder was slightly elevated. There was also abduction of the scapula about 3centimeters from the mid thoracic spine. Superiorly, the scapulas were rotated bilaterally. The pectoralis major muscle had hypertrophied bilaterally. After testing the muscles manually, there was 4/5 strength of external rotation on abduction at 0 and 45 degrees. The patient complained of pain along the anterolateral shoulder. At 30 degrees of abduction, the strength was 3/5 and there was no pain. Based on the above history, Idiagnosed the patient with supraspinatus tendinosis due to shoulder pain which was increased by pull ups, and alot of pain while sleeping the shoulder Running head: HEALTH HISTORY ASSESSMENT 4 which has been affected (Page et al, 2019). The dysfunction on the skeletal muscles was not able to explain the level of shoulder pain and the physical examination did not show the where the pain was exactly located. During the examination, the patient did not maintain good eye contact, he had aflat effect and he spoke in amonotone voice. While describing the effects of the electrical implant his behavior and voice had no meaningful expression. The patient showed some symptoms such as hallucinations, delusions especially about the electrical device which had been implanted on his body which he believed were the source of cold on the knee joints. He also showed some signs of isolation from his friend and family members. All these are indicators of psychosis. (Sprigings, 2018) The symptoms of musculoskeletal dysfunction were inconsistent and this made me to evaluate him for psychosis due to the psychiatric symptoms. Iexplained to the patient that there was need for further medical intervention. Iexplained to the patient that physical therapy was of no help and Ireferred him to apsychiatrist and followed up with the case. At first the patient failed to accept that he had a psychiatric disorder but agreed to cooperate with the psychiatrist. The psychiatrist made similar observations Ihad made and also noticed the psychiatric symptoms after interviewing the patient and doing some physical examination. He noticed that the patient was not athreat to himself and he did not show symptoms of suicidal ideations. After 10 days, the patient was diagnosed with schizophrenia and was started on a dose of risperidone. The patient was to return to the psychiatrist after every two weeks to discuss about the medication and the course of the disease. The interview Running head: HEALTH HISTORY ASSESSMENT 5 Several considerations need to be met when conducting patient interview (Morgan et al, 2018). First, you should introduce yourself and welcome the patient. When referring to the patient use his/her name. Always ensure the patient is ready and avoid all communication barriers when interviewing the patient. Ensure the patient is comfortable. You should always ask open ended questions to the patient to get description of the physical symptoms and listen actively to the patient as he/she provides the answers. Make sure that you confirm that the patient is accurate. Relational approach involves communicating and interacting with other people in amanner that shows respect, humility, cooperation, compassion and inclusiveness. Courtesy and active listening are some of the commonly used relational approaches (Penda, 2017). Communication during health history assessment interview can be both verbal and nonverbal. The communication skills needed during health history assessment include use of non-verbal communication skills, listening attentively, open-ended questioning and summarizing your information. There are several measures applied in order to communicate effectively to the patient. They include maintaining eye contact with the patient, listen attentively and keenly to the patient, avoid interrupting the patient while he/she is speaking and sitting close to the patient. (Boshart, 2019) With regard to interview, developmental considerations refer to attention to development in areas such as cognition, language and emotions. Sometimes the physician or the patient may need to modify their communication so that information is clearly understood by both parties. Communication changes according to chronological age of the patient. During my interview with the patient, Iemployed relational approach by listening to him keenly without interrupting him. Is showed respect to him and sought clarification whenever something Running head: HEALTH HISTORY ASSESSMENT 6 was not clear to me as to understand what he was suffering from. Imade sure that Iovercame communication barriers by using aclear language, making sure that the patient understood what Iwas saying correctly, communicating one thing at atime and respecting the desire of the patient to communicate and also not to communicate. Ialso ensured that Ideal with emotions whenever the patient became emotional. On the developmental considerations, Ihad to use a language which is respectful and not commanding to the patient since he is an adult. Using an authoritative language may make the patient emotional. The health history Assessment factors affecting health of patients includes economic, cultural, familial and social aspects of the life of patient. It also includes patient ’slifestyle on his or her health (Eskelinen, 2017). Information gathered in health history include family history, allergies, social history, past surgical history, past medications the patient has been taking or medication he is taking currently. After interviewing and examining my client I found that he has been taking marijuana occasionally and he is also aconsumer of alcohol. He has an electrical device implanted on his body which is the main cause of his delusions; he has been having pain on the wrist, elbow, ankle, shoulder and the neck. After psychiatric examination, the patient was diagnosed with schizophrenia and was started on adose of risperidone. Social cultural considerations Social and cultural considerations and health determinants to be considered for clients during initial assessment include cultural identity of the patient, social integration, the level of education, infrastructure, social inclusion, community and socioeconomic status (Du Mont et al, 2020). These considerations are important because they contribute to outcome and findings of health Running head: HEALTH HISTORY ASSESSMENT 7 history assessment. Some of priority questions Ican ask my client to elicit information about social and cultural considerations include, asking him what he thinks is the cause of his problems, what kind of treatment he thinks he should receive and how severe is his illness. Iwould ask these three questions because he will answer them according to culture, for example, he can associate schizophrenia with cultural believes such as spirits. Social and cultural considerations and health determinants that need to be addressed in my client include his strong believe that cold in his knee joint is caused by the electrical device implanted on his body and that the pain on his shoulder is alleviated by marijuana. Health promotion One health promotion activity carried out by my client is promoting physical activity. His recreational activities include break dancing, swimming and playing football. Ican implement this activity by encouraging my client to educate the society on the health importance of exercising the body through activities such as swimming, playing football and break dancing. I would educate him on the techniques of carrying out these activities. Conclusion In my work Ihave used apatient with schizophrenia. Ihad severally misdiagnosed the patient. After interviewing the patient, carrying out physical examination and psychiatric examination I found that he had schizophrenia. 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