NURS 210 Week 1 Health History Examination Example

Health History Examination of a Consenting Adult: A 52-Year-Old Office Manager With Seasonal Allergies and Borderline Blood Pressure

Consent and Setting

The history was taken in the volunteer's living room with no one else present, after I explained that it was a course assignment, that nothing that could identify her would go on the form and that she could decline any question. She gave verbal consent. The interview took 45 minutes. D'Amico and Barbarito (2016) describe the health history as the subjective data on which the physical examination builds, and as a conversation that depends on privacy, respect and open questions.

Biographical Data

Ms. R., 52, is employed full time as the office manager for a dental practice. She is married, has two adult children and lives with her husband in a two-story house. She identifies as Christian and attends church weekly. Her primary language is English, and she completed an associate degree. She has employer health insurance and sees a primary care provider once a year. She is a reliable historian.

Reason for the History

Ms. R. volunteered for a course assignment and has no acute complaint. When asked about current concerns, she said, "My blood pressure was 142 over 88 at the pharmacy machine last month, and I've been wondering if I should worry about it."

Present Health

Current health: She describes her health as "pretty good for my age." She reports occasional tension headaches, about twice a month, relieved by ibuprofen, and seasonal allergies each spring and fall.

Medications: loratadine 10 mg by mouth daily during allergy season; ibuprofen 400 mg by mouth as needed for headache, about twice a month; a daily multivitamin. No prescription medications.

Allergies: penicillin, which caused a rash as a child; seasonal pollen. No known food or latex allergies.

Health practices: She walks for 30 minutes three evenings a week, uses sunscreen in summer and wears a seat belt. She has not had her blood pressure checked by a clinician since her annual visit eleven months ago, when she recalls it was "normal."

Past Health History

Childhood illnesses: chickenpox at age 7; no rheumatic fever.

Medical conditions: seasonal allergic rhinitis since her twenties. No diabetes, heart disease, lung disease or cancer.

Surgeries and hospitalizations: cesarean birth at age 27; vaginal birth at age 30; appendectomy at age 35. No other hospitalizations.

Immunizations: reports a tetanus booster six years ago, annual influenza vaccines and the COVID-19 primary series. Unsure about shingles vaccination.

Screenings: mammogram last year, normal; colonoscopy at age 50, normal, with a ten-year follow-up interval recommended. Current national recommendations support biennial mammography for women aged 40 to 74 (US Preventive Services Task Force, 2024) and colorectal cancer screening for adults aged 45 to 75 (US Preventive Services Task Force, 2021), so both screenings are up to date. Last Pap test three years ago, normal.

Family History

Father: age 78, living, hypertension diagnosed at 50 and a heart attack at 70. Mother: died at 74 of breast cancer, diagnosed at 68. Brother: 55, type 2 diabetes. Sister: 49, healthy. Paternal grandfather: died at 66 of a stroke. Paternal grandmother: died at 80, cause unknown to the volunteer. Mother's parents: each lived into their eighties; she knows of no specific cause ("old age"). Children: son 25 and daughter 22, both healthy. The family history includes hypertension, coronary disease and stroke on the father's side, type 2 diabetes in a sibling and breast cancer in the mother.

Psychosocial and Lifestyle History

Work and home: She enjoys her job but describes it as "busy and noisy," with deadlines at the end of each month. Her marriage is supportive. Her daughter recently moved out of state, which she described as "harder than I expected."

Stress and coping: She rates her stress as 5 out of 10, higher at month's end. She copes by walking, praying and talking with her sister.

Sleep: six to seven hours a night; she sometimes wakes at 3 a.m. and has trouble falling back asleep.

Nutrition: three meals a day, often fast food for lunch at work; she estimates she eats salty snacks most afternoons. Two cups of coffee daily.

Substances: never smoked; one glass of wine on weekends; no recreational drug use.

Spirituality: Her faith is "very important"; she volunteers in her church's food pantry once a month.

Review of Systems

General: no fever, weight loss or fatigue; reports a weight gain of about 8 pounds in the past year.

Skin: no rashes or lesions; a mole on her back she has watched for years without change.

Head: tension headaches as above; no head injury or dizziness.

Eyes: wears reading glasses; last eye exam two years ago; no blurred vision, pain or discharge.

Ears: no hearing loss, ringing or discharge.

Nose and sinuses: seasonal congestion and sneezing; no nosebleeds.

Mouth and throat: dental visits twice a year; no sores or hoarseness.

Neck: no lumps, stiffness or thyroid problems.

Respiratory: denies cough and wheezing; walks up a flight of stairs without getting winded.

Cardiovascular: denies chest pain and a racing or skipping heartbeat; no ankle swelling at the end of the day; the pharmacy reading noted above.

Breasts: performs breast self-awareness monthly; no lumps or discharge.

Gastrointestinal: no heartburn, nausea or change in bowel habits; regular daily bowel movements.

Urinary: no burning or frequency; occasional leakage when sneezing.

Reproductive: menstrual periods have become irregular over the past year, with hot flashes at night.

Musculoskeletal: occasional lower back stiffness in the morning; no joint swelling.

Neurological: no numbness, weakness or seizures.

Mental health: no persistent sadness; mild worry about her daughter, as noted.

Endocrine: no excessive thirst or urination; no heat or cold intolerance other than hot flashes.

Summary for the Physical Examination

The history points to several findings for the examination to follow up: blood pressure, measured properly in both arms; weight and body mass index given the reported weight gain; the long-standing mole on her back; the nasal mucosa during allergy season; and her report of stress-urinary leakage and perimenopausal symptoms, which she may wish to discuss with her provider. Her family history of hypertension, coronary disease and stroke makes the blood pressure concern worth taking seriously, but a single kiosk reading is not a diagnosis, and the history records it as she reported it. A good history tells the examiner where to look; it does not decide in advance what will be found.

References

D'Amico, D., & Barbarito, C. (2016). Health and physical assessment in nursing (3rd ed.). Pearson.

US Preventive Services Task Force. (2021). Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA, 325(19), 1965-1977. https://doi.org/10.1001/jama.2021.6238

US Preventive Services Task Force. (2024). Screening for breast cancer: US Preventive Services Task Force recommendation statement. JAMA, 331(22), 1918-1930. https://doi.org/10.1001/jama.2024.5534