NUR 3280 Module 2 Health History and Interview Example

Organizing What the Client Said: A Complete Health History for a Forty-Nine-Year-Old Delaware Bay Oyster Harvester

Student Name

Accelerated B.S.N. Program, Thomas Edison State University

NUR-3280: Health Assessment and Health Promotion

Mentor Name

Month Day, Year

Organizing What the Client Said: A Complete Health History for a Forty-Nine-Year-Old Delaware Bay Oyster Harvester

The second module asks for a complete health history obtained through interview, with the subjective data organized in a standard format and a short analysis of the process. The client is the volunteer from my first paper, with identifying details changed as before. The interview lasted about forty minutes and followed the structure described by Jarvis and Eckhardt (2024): biographical data, reason for seeking care, present health or history of present illness, past health, family history, review of systems and functional assessment. The history is presented first, in the form a nurse would document it, and the analysis follows.

Biographical Data and Reason for Visit

The client is forty-nine years old, lives with a partner and an adult child in a single-family home, completed high school, and has worked on oyster dredge boats on Delaware Bay for twenty-six years, currently as a deckhand on a family-owned boat from March through December. The client is insured through a spouse's employer plan and reports no regular primary care visits in the past four years. The client's source of information is the client, who appeared reliable and consistent. There is no acute reason for the visit. The client agreed to a wellness assessment as a volunteer for my course and named one concern in their own words: whether the rough patches on my face are cancer.

Present Health and History of Present Illness

The client describes general health as pretty good for my age. The main symptom is low back pain, which I explored with a full symptom analysis: when it started, where it sits, how long it lasts, what it feels like, what worsens and eases it, its pattern over the week and how bad it gets. The pain began about eight years ago, gradually, without a single injury. It is located across the lower back on both sides without radiation into the legs. It is a dull ache, worse at the end of the work week and after long days hauling dredge bags, relieved by rest, a heating pad and over-the-counter ibuprofen taken two or three days a week during the season. The client rates it as four out of ten at worst. There is no numbness, weakness, bowel or bladder change, fever or weight loss, which are the symptoms that would raise concern for a more serious cause.

The second issue is the skin. The client has noticed rough, scaly patches on the forehead, nose and backs of both hands for about two years. They sometimes flake off and return. The client has not noticed any mole that changed in size, shape or color, and has never had a skin examination. Sun protection is limited to a cap; the client does not use sunscreen and says it washes off in the spray.

Past Health, Medications and Allergies

The client reports usual childhood illnesses and no chronic diagnoses, though they have not been screened recently for blood pressure, cholesterol or diabetes. Past injuries include several hand lacerations from shells, one of which became red and swollen about five years ago and was treated with antibiotics at an urgent care center after a day on the water. There have been no hospitalizations or surgeries. Immunizations are uncertain: the client believes the last tetanus shot followed the infected cut. Current medications are ibuprofen 200 to 400 milligrams as needed and no supplements. The client reports no known drug or food allergies and no reaction to shellfish.

Family History

The client's father, also a waterman, had long-standing high blood pressure and died suddenly of a myocardial infarction at sixty-eight. The mother is seventy-four and has type 2 diabetes. One brother, fifty-two, has high blood pressure. There is no known family history of skin cancer, though the client noted that no one in the family has been checked. The family history therefore points toward cardiovascular disease and diabetes as risks to screen for, in addition to the occupational risks.

Review of Systems and Functional Assessment

Review of systems was negative except as follows. Skin: scaly patches as above, frequent small cuts on the hands. Ears: the client often asks family to repeat themselves and keeps the television louder than others like; there is constant engine noise on the boat and the client does not use hearing protection. Musculoskeletal: low back pain as above and morning stiffness in the hands in cold weather. Respiratory: a morning cough with clear sputum most days. Cardiovascular, gastrointestinal, genitourinary, neurological and psychiatric reviews were otherwise negative.

Functional assessment covered daily life and health behaviors. The client has smoked for twenty-two years, currently about a pack a day, and has tried to quit twice. On the three alcohol consumption questions validated by Bush et al. (1998) as a brief screening test, the client's score was six, driven by four or more drinks on weekend evenings, which is above the commonly used screening thresholds and warrants a follow-up conversation. Sleep is about six hours a night during the season, starting at 4 a.m. Meals are irregular, often fast food at the dock. The client walks a great deal at work but does no other exercise and feels in good shape because the work is physical.

How the History Was Organized and What It Shows

Organizing the history in this sequence did more than satisfy a format. Placing occupation in the biographical data, rather than leaving it for the functional assessment, meant that every later section was read through it: the skin findings in light of sun exposure on the water, the hand cuts in light of shells and brackish water, the hearing complaint in light of engine noise, and the back pain in light of lifting. The infected cut in the past history is relevant beyond the hand, because cuts exposed to warm coastal water can become infected with Vibrio species, which can cause serious wound infections (Centers for Disease Control and Prevention, 2024). The client did not know this, and it will become part of the health promotion plan later in the course.

The history also sets priorities for the physical examination. Skin, ears, musculoskeletal system, lungs and cardiovascular system all need careful examination, and the family history adds blood pressure and diabetes screening. The one concern the client raised, the patches on the face, should be addressed directly in the next visit, because a client whose question is answered is more likely to return for the rest.

References

Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789-1795. https://doi.org/10.1001/archinte.158.16.1789

Centers for Disease Control and Prevention. (2024). About Vibrio infection. https://www.cdc.gov/vibrio/about/index.html

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.