Health History: Subjective Data

Patient XA is a 35-year-old Caucasian male born on February 24, 1987. He works as a
Software Engineer in one of the major technology companies in the United States and is happily
married and blessed with three children, two boys and a daughter. He lives in Los Angeles with
his family. This assessment is being obtained as a regular check-up. Patient XA perceives
healthy living and practices a healthy diet and exercise. He only complains of intermittent diffuse
headaches and pains resulting from his overindulging occupation. Patient XA has a history of
Acid reflux but has been managing it with daily intakes of omeprazole. In addition, he regularly
takes daily vitamins. He also reports having undergone reconstructive surgery after a near-fatal
car accident and inguinal hernia repair. The patient’s father has a history of hypertension, while
the mother has a history of dementia and hypertension. His grandmother passed away from
congested heart failure and chronic UTIs.
Regarding the review system, Patient XA has denied fever and chills. The patient also has
no skin concerns, such as lesions. He reports no cases of hair loss or change in texture. His nails
are okay and have not changed in curvature, texture, or color. Patient XA says he experiences
intermittent headaches but insists it is due to stress at work. He also denies feeling faint or dizzy.
Patient XA denies any vision or eye pain. He has no history of infections, hearing loss, or
earaches. No throat or mouth pain. No bleeding, lesions, or sores were recorded. He
acknowledges that he occasionally experiences back pain but claims that this is typical because
of the nature of the job, and he treats it with Ibuprofen. Patient XA denies having chest pain or
loss of breath. He mentions smoking in public. Reports infrequent alcohol use but denies using
drugs. He eats voraciously. Without any rectal bleeding, bowels are normal. Although he does

mention some modest frequency and straining to urinate, he claims that this is a side effect of
having his inguinal hernia repaired.
He reports being raised by a single mother under a co-parenting agreement with the
father. They lived in New Orleans, LA, while the father lived in New York. The patient was
raised in a catholic household and still goes to church every Sunday because he believes in
miracles and God’s healing. As a 38-year-old young adult, patient XA is in the sixth stage
(intimacy vs. isolation) of Erik Erikson’s theory of psychosocial development. He enjoys a solid
and deep romantic relationship with his wife, close ties with friends and family, and a robust
social support network. However, he does not live with his mother but is near and visits her
almost daily to check on her. He also did not have a close relationship with his father while
growing up, but they have been working on their relationship recently. His family is emotionally
supportive, and he reports having a history of anxiety but attributes it to work pressure. As a
staunch Christian, patient XA also enjoys deep and meaningful connections with church
members and often receives emotional and social support from them. Workmates and neighbors
are also emotionally and financially supportive.

Physical Exam: Objective Data

Regarding the assessment, Patient XA is attentive and situationally aware. His vital signs
are within the normal ranges, including BP of 120/80 mmHg, HR 66 bpm, TEMP 98.3 F, 100%
SpO2, and RR 18 bpm. He disputes any discomfort or agony. The patient’s skin is unblemished
and has an even tone suitable for his ethnicity. No rashes, lesions, abrasions, or edema. He has
smooth and evenly spaced-out hair. There are no indications of head tumor or pain. The head
morphology is normal, with no signs of tumors, lesions, or pain. The physical appearance of the
face is symmetrical, with no infestations or lesions on the eyebrows or eyelashes.

For the eyes, the conjunctiva is pink while the sclera is white with equally rounded,
responsive to light, and accommodating pupils. Bilateral ears are not sore, red, or swollen. The
nose is symmetrical with the rest of the face and has no septum deviation. The patency is also
regular. The lips are thin and pink. A mouth exam shows that the oral mucosa appears moist and
pink, with no signs of tumors or nodules. No smell. The soft palate and uvula rise to the midline.
Also, the patient has no scoliosis, kyphosis, or lordosis symptoms in the posterior chest. The
expansion is bilaterally symmetrical, and the AP diameter is smaller than the transverse
diameter. The patient has audible chest vibrations with no apparent bulk or softness. Auscultated
breath sounds and unmistakable sounds can be heard throughout. Findings of a bilateral radial
pulse with 2+ pulses were used to evaluate the peripheral vascular system. Upon observation, the
abdomen appears symmetrical and flat with a bit of roundness. The umbilicus is centered. There
are no indications of discharge or edema. Auscultation of bowel sounds is normal. The abdomen
is slightly rough to the touch and painless. No signs of stomach bloating.
Patient XA can walk on his own without assistance. Without any apparent abnormalities,
the gait is stable. On the bilateral upper and lower extremities, muscle strength is a five-point. He
can move in all directions. A neurological evaluation is typical. Speech is unhampered, and both
hearing and memory are still functional. In general, patient XA cooperated with the examination.

Needs Assessment

Based on patient XA’s physical examination and health history, the following two health
education needs must be addressed: training on alcohol cessation and dietary intake to control
acid reflux. According to Jensen (2017), stopping alcohol consumption is a critical factor in
reducing episodes of acid reflux as this reduces the lower esophageal sphincter pressure,
facilitating reflux. Furthermore, Johnson (2020) notes that alcohol causes patients to urinate

more, which could lead to dehydration and worsen acid reflux symptoms. To prevent worsening,
avoiding foods that aggravate acid reflux symptoms, including milk, caffeine, and citrus fruits, is
also essential. Patient XA should also consider eating small meals frequently and avoid eating
three hours before sleeping (Konusky & Avital, 2020).
Unhealthy eating habits and alcohol addiction are the two major behavioral and
psychosocial factors that can impede the effectiveness of the proposed educational program. The
family’s dietary traditions and cultures (such as meal time frequencies, food quantities, and types
of foods cooked and served) can also hamper the success of the proposed dietary plan. However,
individual strengths (friends, family, and personality) and collaborative resources (community,
clinical, and health & wellness facilities) can significantly bolster the chances of the proposed
teaching plan succeeding. For example, patient XA has a supportive family willing to stick to the
proposed dietary plan. Patient XA also has a strong determination and will to quit alcohol and
make healthy food choices. A community rehabilitation center can provide a perfect place for the
patient to recover from alcohol dependence.
Reflection

For this interview, Patient XA was approached and informed about the requirements,
thus, obtaining his consent. Patient XA was told that the interview would take no more than 10
minutes and that his information was to remain private. The assignment was based on classroom
learnings and my expectations. Most of the time, the conversation flowed as I expected it to.
However, we experienced frequent interruptions from his younger son, which did not negatively
impact the interview. The physical examination went on perfectly since I had the essential
equipment. The assignment turned out well, and all the required data was collected successfully.
The physical exam was easy to perform since I was provided with a table and a couch where I

was able to examine the abdomen. Both the health history and physical examination were carried
out well and successfully. I do not think there is anything I would wish to change next time apart
from interviewing a female patient.

References

Johnson, J. (2020). What to know about alcohol and heartburn. Medical News Today.
https://www.medicalnewstoday.com/articles/alcohol-heartburn
Kornusky, J., & Avital, O. (2020). Acute myocardial infarction.
https://www.ebsco.com/sites/g/files/nabnos191/files/acquiadam-assets/Nursing-
Reference-Center-Plus-Quick-Lesson-Acute-Myocardial-Infarction.pdf
Ness-Jensen, E., & Lagergren, J. (2017). Tobacco smoking, alcohol consumption and
gastroesophageal reflux disease. Best Practice & Research Clinical gastroenterology,
31(5), 501-508.