MSN 572 Week 1: Health History Interview and Risk Assessment

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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

1. 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).

1. 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).

1. 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

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