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Health History Assessment and Physical Assessment

Health History Assessment and Physical Assessment

Sample Answer 

Health History Assessment and Physical Assessment

Subjective Data

James Clarkson is a 30-year-old African American male, living with his two kids (7-year-old son John and 3-year-old daughter Gianni) and wife, Jessica Simpson. Since he earns less than $25,750 annually working as a coal miner, Clarkson lives in low-income housing in Arlington, Virginia, with his family of four. The neighborhood is considerably insecure, with poor health facilities, internet connection, food supply, and other infrastructure.

Today, Clarkson is visiting the healthcare facility for a general checkup. As a coal miner, the client feels that he is often predisposed to poisonous chemicals and, thus, needs to constantly visit a medical facility for a health assessment. The patient is healthy, with no underlying or secondary condition. The patient reports no previous medications and allergies, except for the influenza and malaria vaccines taken in January 2020 during the peak of the winter season. For the family history, the patient indicates that his grandmother and mother both succumbed to breast cancer. Coincidentally, the grandfather and father have also been previously diagnosed with high blood pressure and type 1 diabetes. His children, as well as close relatives, are also showing signs of getting overweight and obese.

All the patient’s body systems are performing normally, including circulatory, nervous, blood, sensory, muscular, renal, endocrine, and renal systems. However, Clarkson holds several future developmental, cultural, and psychological considerations. In terms of development, the patient’s main concern is the overweight and obese problem that is affecting his entire extended family. Clarkson fears that if something is not done promptly, his kids might become obese. He is contemplating including a diet rich in vitamins and vegetables instead of red meat on the family’s menu. Psychologically, Clarkson is considering visiting a health professional, counselor, nutritionist, nurse, and physician to strengthen his mental capacity to deal with chronic conditions such as cancer. Culturally, the patient’s main concern is the notion that African Americans characteristically eat barbecued ribs, fried chicken, and sweetened foods as opposed to vegetables because they rarely consider dieting and weight loss as an option.

Objective Data

Generally, the patient appears clean, well-dressed, alert, awake, and X-3-oriented. The vital signs are oxygen saturation (99% at room temperature), blood pressure (98/66 mmHg), respiratory rate (15), heart rate (76 beats per minute), temperature route (tympanic), and temperature (98.7 °F). The patient weighs 41 Ibs, with a height of 54 inches. On the other hand, the skin is tough, dry, turgor good, and warm, with a capillary refill of +3. No lesions, tenting, trauma, ecchymosis, or rashes were observed. For the HEENT, the patient has thick, evenly distributed facial hair with no lesions, masses, or lumps. The head appears normocephalic, with no tenderness observed during palpation. The tympanic membranes are intact and grey, while the tragus and pinna are non-tender. The turbinate is moist and pink, the nares and pharynx have no exudates, the mucous membrane is dry, and the tonsils are barely visible (+ 1). For the PERRLA assessment, his conjunctiva appears non-icteric and clear.

The neck is full and supple, with no lymphadenopathy. Cardiovascular system assessment shows that both S1 & S2 are present and normal, with no murmurs, opening snaps, gallops, as well as rubs. There was no pain during chest wall palpitation.

Needs Assessment

From the needs assessment above, it is clear that Clarkson requires health education in two major areas. Firstly, Clarkson needs training on dietary choices to avoid predisposing his family to overweight, obesity, diabetes, and the resulting co-morbidities, such as heart diseases. Secondly, Clarkson must improve the cultural problem of African Americans, especially in relation to the food perspective. He must deal with the problem of dieting among blacks that is affecting the achievement of health, including control of overweight, obesity, diabetes, and other co-morbidities. Finally, two peer-reviewed journals can give evidence-based and empirical support for the health education needs mentioned above. For the first case scenario, Nour et al.’s (2018) article can be handy because it recommends using vegetables to improve weight outcomes. For the second case, Li et al.’s (2017) article provides enough evidence to demonstrate that blacks rarely engage in dieting practices, which is why a majority often experience overweight, obesity, diabetes, and other nutritional problems.


Li, W., et al. (2017). Racial differences in eating patterns and food purchasing behaviors among urban older women. Journal of Nutrition Health & Aging, 21(10), 1190-1199.

Nour, M. et al. (2018). The relationship between vegetable intake and weight outcomes: A systematic review of cohort studies. Nutrients, 10(11).


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Health History Assessment and Physical Assessment

Health History Assessment and Physical Assessment

Health History Assessment and Physical Assessment

APA format

  • Health assessment on healthy 30 years old male. Healthy, no secondary conditions. Do not include reflection part ( I will write it on my own)

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