RUA Health History and Physical Assessment
Health History: Subjective Data
G. N. is a 60-year-old African American male born in African but migrated to the United States at the age of 20 years with his parents. His primary language is Shona. His height is 5-foot 3 inches, and his weight is 300 pounds. He is divorced and is presented to the hospital for his annual checkup but has no major concerns. He goes to the gym regularly and tries to eat a balanced diet, so he considers himself to be healthy. He does not smoke but drinks at the pub every week with some friends for social interaction. G. N’s vaccinations are all up to date and he received additional vaccinations upon entry to the United States to be compliant with the Immigration laws. He participates in all recommend and mandatory vaccines including Covid-19 vaccine and flu shots yearly and has never had any surgery. He has no known medication allergies other than sinus allergies which are seasonal, and well managed. Both his parents passed away due to Covid 19 in July 2020, but they did not have any chronic illnesses.
G.N states no redness or skin rashes and no trauma injuries of any kind on his head. He wears corrective lenses due to continuous use of computers during work giving him migraines. He states no ringing in the ears or any inflammation in the nose or throat. G.N denies the use of any assistive devices to help with breathing and has no shortness of breath when doing activities. He added that he has great appetite and maintains a balance died full of fiber and lots of fluid to avoid any constipation. His urinary system is intact, and he denies any previous urinary infections or retention. G.N pointed out that he has recently started having back and knee problems when he exercises.
Looking at G. N’s age, he is currently at the Generativity vs. Stagnation stage of psychosocial development where he is striving to find survival methods that last for generations to come to fight any possible chronic diseases that may be in their family history. He stated that because he was from Africa, they grew up chewing on traditional herbs given by the elderly to protect them from diseases that are communicable, or air borne. He explained that these herbs worked as antibodies that helped make their immune systems stronger and well prepared to attach foreign pathogens. Apart from his strong Africa beliefs in herbs, he maintained that he is a Christian.
Physical Examination: Objective Data
The physical assessment for this patient is not complicated and has no alarming concerns. His blood pressure is 126/78, which is within normal limits. The oral temperature is 98.4°F (37 C), his heart rate is 60 beats per minute, is regular, with respirations of 18. His oxygen saturation is 96% of the room air. His pain scale is a 0 on a 0-10 pain scale. G. N’s head is bold and round, with no lesions or infestations. The sclera is white and the conjunctiva is pink with no drainage. His pupils are symmetrical and equal in size, round, reactive to light, and accommodation. G. N’s external nose is symmetrical with no discoloration, swelling or deformities. Nasal mucosa is pinkish red with no discharge or bleeding or foreign bodies. Patency was noted upon testing both nares. The ear canal has small hairs with yellowish earwax. He reported no difficulty hearing and passed the whisper test. No tenderness upon palpating the thyroid and lymph nodes. Upon assessing his cardiovascular system, he had regular heart sounds with no murmurs noted. Lung sounds were clear, with no labored breathing or adventitious sounds, proving that his respiratory system is intact. G.N was well aware of who he was, where he was, what he was doing, what time and date it was.
His abdomen had a rounded and symmetrical contour. His bowel sounds are normal within each quadrant. He reported his last bowel movement was today before he left his home. No tenderness or distention on palpation was noted.
G.N has good ROM and muscle strength on both lower and upper extremities and a steady gait. All the cranial nerves seem intact. G.N is well invested in his health. He is on a weight loss program to lose weight and maintain a healthy BMI because he is on the borderline of being diabetic. To help achieve his goals I would recommend continuing a routine exercise or weight loss program with a guided diet and replacing alcohol with healthier drinks and juices to keep him hydrated. Studies have proven that alcohol intake can cause weight gain by stopping the body from burning fat because it is high in kilojoules and may lead to unhealthy cravings for salty and greasy foods. The fact that G.N. is divorced and does not live in a family-oriented home where meals are cooked and shared at home, it is very important to encourage health promotion with the people around him. He is a divorced man and often relies on take away food and alcohol at the pub weekly which might contradict his mission of losing weight. Good friends will encourage the importance of living a healthy lifestyle and can support them by helping him make better choices.
Reflection
My interaction with this patient was very educating and informative to me personally. I learned that culture plays a big role in molding a person, especially if they migrate from one culture to another. People often struggle with being between cultures and the different lifestyles that come with that. Perceptions of health and approaches to health promotion are affected mainly because cultural bias may result in different health related preferences.
The patient was very open about their culture and how weekly meetings at the pub with friends was an important sport to maintain relationships with the alfa male. The health assessment course helped me understand and use the best approach by not passing my own judgement and opinion on how the patient should improve their lifestyle. I was able to incorporate some ideas that were useful like maintaining a schedule at the gym with a guided diet which the patient received very well. I had no major challenges during this assignment because my patient had no family history of chronic illnesses. Considering that this patient’s grandparents were from Africa, he did not have enough information about them except the little information he got growing up from his late parents. It would have made a lot of difference getting a chance to interview his parents to gain clarity on any previous health history.
References
Jerlhag E. (2019). Gut-brain axis and addictive disorders: A review with focus on alcohol and
drugs of abuse. Pharmacology & therapeutics, 196, 1–14. https://doi.org/10.1016/j.pharmthera.2018.11.005
Witkiewitz, K., Kranzler, H. R., Hallgren, K. A., O’Malley, S. S., Falk, D. E., Litten, R. Z.,
Hasin, D. S., Mann, K. F., & Anton, R. F. (2018). Drinking Risk Level Reductions Associated with Improvements in Physical Health and Quality of Life Among Individuals with Alcohol Use Disorder. Alcoholism, clinical and experimental research, 42(12), 2453–2465. https://doi.org/10.1111/acer.13897
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