MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.

MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.


Advanced Health Assessment: Documenting the Subjective History of a 48 Year-Old African American Man with a History of Smoking

Source of History and Reliability: A family friend of long standing who is a family man and therefore very reliable.MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.


  1. Biographical Data

A.J.C is an African American male whose first language is English (American). He is 48 years old and was born on July 6th 1972 in Memphis Tennessee. He has been married for the last twenty-four years and has four children. Ethnically he is of African descent. He is a travel consultant and possesses an undergraduate college degree. Currently, he is covered by commercial health insurance paid for by his employer.  MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.

  1. Chief Complaint (reason for seeking health care):

Mr. A.J.C complains of left-sided chest pain that is radiating to the back for the past one week. He reports that the pain has been coming on and off but is more frequent when he engages in physical activity that is as simple as just walking. He says that the pain typically lasts for about three minutes and then stops when he stops the physical activity he was doing.MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.

  1. History of Present Illness (HPI):

Mr. A.J.C is a 48 year-old African American male who presents with intense chest pain. The pain is located on the left side of the chest but radiates to the shoulders and the back. It started exactly seven days ago and is a “tight and squeezing” pain. The pain is associated with difficulty in breathing and a lot of anxiety or “a feeling of impending doom” as narrated by Mr. A.J.C. It is more frequent at times of physical activity such as walking and is exacerbated by exertion and the drinking of coffee. It may occur two to three times in a day and lasts on average for three minutes or until physical activity is stopped. The pain is relieved by complete rest. He rates the severity of the pain at 7 out of 10 on the pain scale (Ball et al., 2019; Bickley, 2017). The patient’s reason for seeking care is that the pain has now become more frequent and is beginning to occur at times even when he is at rest. He perceives the problem as being caused by his smoking but he cannot tell exactly how.MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.

  1. Past Medical History
    1. Medical Hx: He is a type II diabetic for the last ten years and has been battling obesity with the latest body mass index (BMI) being 31.0 kg/m2. He has also been having hypertension for the past eight years. He has been hospitalized three times before for pneumonia, surgery, and a very high blood pressure. He has never received any blood transfusions and has no obvious disability.
    2. Childhood Illnesses: He suffered from type-A beta-haemolytic streptococcal sore throat as a child. He has no other history of suffering from childhood illnesses such as measles, whopping cough, mumps, chickenpox or rubella.
    3. Surgical Hx: At age 38, he had an operation to correct an inguinal hernia. He also underwent appendectomy three years ago. Both surgical operations were done as an inpatient. MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.
    4. Obstetric History: Not applicable.
    5. Immunizations: He got all immunizations as a child for diphtheria, pertussis, tetanus, pneumonia, measles, and tuberculosis. He has also received the flu vaccine.
    6. Psychiatric History: He denies any history of psychiatric illness either as a child or as an adult.
    7. Allergies: He denies any known allergies for medications, food products, or any other environmental irritant.
    8. Current Medications: He is currently on the prescription medications atorvastatin (Lipitor) 40 mg qd, metformin (extended release) 1,500 mg qd, and a combination pill of losartan with hydrochlorothiazide or HCTZ known as Hyzaar at a dose of 50 mg/12.5 mg q12h. He is taking omega-3 supplements that he buys over the counter (OTC) but is not on any herbal remedies. He is also regularly taking OTC acetaminophen 1 gram PRN when he has the pain.
    9. Last Examination Date: He last got examined three months ago with the following tests being done: full blood count (FBC), electrocardiogram (ECG), serum cholesterol levels, and liver function tests (LFTs).MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.
    10. Family History
  • His spouse and four children are all alive and well.
  • Both of his parents are deceased, the father from heart failure and the mother from myocardial infarction or heart attack. The grandparents are also deceased.
  • None of his other immediate family members has a history of chronic illness.
  1. Life style patterns

Mr. A.J.C is an American citizen by birth and therefore not an immigrant. He is a Christian and occasionally goes to church but is not very religious. He understands the need to live a healthy lifestyle, especially after getting repeated health education concerning the need for him to reduce his weight, eat plenty of fruits and vegetables, and exercise regularly. On nutritional patterns, he is currently following a strict low calorie low fat diet with small frequent portions instead of large meals at one sitting. His current BMI of 31.0 kg/m2 indicates obesity and he is not happy with it. However, it is better now because he has lost 20 kg in the last one year out of regular isotonic and resistance exercise as well as dietary discipline. He reports no cultural dietary restrictions and takes copious amounts of plain water each day.MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.

He reports regular and normal bowel and bladder patterns with no incontinence. He currently lives in his state of birth which is Tennessee in the city of Memphis. He is part of a suburban community that lives in good housing with electricity, running water, good drainage, and a good sewerage system. He reports no known environmental pollutants in his locality. Being a travel consultant, he is not exposed to any environmental toxins at work. He is functionally active and can carry out activities of daily living (ADLs) and instrumental ADLs (IADLs) by himself up to this moment. However, he feels that this is beginning to change with the chest pain starting to attack even at rest. He is the principal bread winner in his family, although his wife also works as a school administrator thereby helping him with the bills. His family is a closely knit nuclear family made up of himself, his wife, and four children (two boys and two girls). Family decisions in his household are made through consultations, first between him and his wife then involving their children. The impact of his ill health to the family will be immense, given that three of the children are still in school and college. MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.

His cognitive functions are reported as being normal. This includes his memory, speech, judgement, and senses. He has been having disturbances in his sleep patterns of late waking up several times in the night due to discomfort unlike before. He used to sleep for at least eight hours but now he can only manage five hours on a good night. He does not experience naps during the day. At night, he feels more comfortable to sleep with more pillows under his head and chest to prop him up. This started after the chest pain started becoming more and more frequent. He denies using any sleeping pills to aid sleep. For exercise, he follows a strict routine of daily isotonic exercise (walking) for five days in a week as was prescribed for him by diabetes physician. This is now becoming impossible because of the chest pain.MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.

Mr. A.J.C loves travelling, watching football, and is also a car enthusiast. He also likes swimming although his weight has been making him avoid it lately. Once per year, he loves taking his family on vacation to West Africa to visit the place “where their ancestors came from.”  He has been smoking for the last thirty years and has only recently been put on a smoking cessation program after his weight, blood pressure and serum low density lipoprotein cholesterol (LDL-C) started showing lack of control. He occasionally drinks over the weekend with friends but has no history of street drug use or substance abuse. He denies any gender-based violence towards him or towards his partner. He reports coping with stress through the reassuring psychological support of his wife. In this context, one major recent life change has been the effect of the novel coronavirus or Covid-19 pandemic on travel and tourism. This has meant that he is out of work since May 2020. This has given him anxiety as he has been forced to cancel this year’s vacation and use the savings for other essential needs. Lastly, he denies any sexual dysfunction although admits that his sexual life is not as active as it used to be before his weight increased. He reports that he is straight and nothing has changed about his sexual preferences or health.   MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.

III. Review of Symptoms

System Pertinent negatives and/or positives


General Pertinent negatives: No fevers

Pertinent positives: Positive weight loss in recent months, some fatigue and weakness.

Skin No rash, no sores or lumps, no itching or dryness, no abnormalities in hair and/ or nails.
Head No headache, no head injury or history of syncope.


No double vision, no pain/ swelling or redness, no blurring, and no tearing. Last eye examination done on 12/01/2020.
Ears No otorrhea, no earache, no pain, no tinnitus, no loss of hearing, and no ear infections.


No rhinorrhea, no epistaxis, no nasal congestion, no itching, and intact sense of smell.


No oral lesions, no toothache, no gum bleeding, no sore throat, no tonsillectomy. Sense of taste intact. Last dental examination on 06/12/2019.
Neck No palpable cervical nodes, no evidence of goiter, no neck stiffness or pain, and no limitation of movement.
Breasts No palpable lumps or masses, no nipple discharge, no rash.
Pulmonary Pertinent negatives: No cough, no hemoptysis, no wheezing.

Pertinent positives: presence of dyspnea especially during exertion.

Last chest X-ray done in 2018

Cardiac Pertinent positives: squeezing chest pain especially during physical activity, presence of hypertension.
G/I No nausea/ vomiting, no dysphagia, no heartburn, no ain or flatulence, no stool abnormalities, no hemorrhoids, no constipation, no diarrhea or food intolerance.
Genito-Urinary No dysuria, no nocturia, and no hematuria.

Shortened stream, no drastic change in sexual habits, no genital sores or pain, no masses, and no known HV exposure.

Peripheral-Vascular No intermittent claudication, no paraesthesia, no varicose veins, no cramps, no ulcers or discoloration of extremities.
Musculo-skeletal No joint stiffness or pain, no limitation of movement, no history of gout or arthritis.
Neurologic No paralysis, no stroke, no numbness or tingling, no tics, no involuntary movements, no memory loss, no mood changes, no seizures, no coordination problems, no history of mental illness.
Hematologic No history of anemia or blood transfusions, no swelling of nodes, no exposure to radiation.
Endocrine Pertinent negatives: No cold/ heat intolerance, no excessive thirst, no excessive drinking of water, no excessive passage of urine, no thyroid disease, no history of hormone replacement, and no abnormal hair distribution.

Pertinent positives: positive history of type II diabetes.


Psychiatric No nervousness, no anxiety, no changes in memory, no suicidality, no depression, and no history of mental illness.

Please select a volunteer friend or family member to interview and gather data to complete this Assignment. The following guide will assist you in gathering subjective data in an organized, systematic manner to prevent omission of important components of the health history.MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.


Date of History/Interview:

Source of history and Reliability:

Biographical Data

  1. Name (use initials only)
  2. Primary language
  3. Age and Date of Birth
  4. Place of Birth
  5. Gender
  6. Race
  7. Marital Status
  8. Ethnic/Cultural Origin
  9. Education (highest level completed)
  10. Occupation/Professional
  11. Health insurance (ie commercial, state, federal)


  1. Chief Complaint (reason for seeking health care):
    1. Brief spontaneous statement in client’s own words
    2. Includes when the problem started ( “chest pain for 2 hours”)


  1. History of Present Illness: A well organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the OLD CARTS

P – Provocative or palliative (What brings it on? What makes it better or worse?)

Q – Quality or quantity (Describe the character and location of the symptoms; How does it look, feel, sound?)

R – Region or radiation (Where is it? Does the symptom radiate to other areas of the body?).

S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).

T – Timing (Inquire about time of onset, duration, frequency, etc.)

U – Understand Patient’s Perception of the problem (What do you think it means?)

** Put all of that information into the heading HPI in a story format.

  1. Past Medical History (list down not across)
    1. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and disabilities
    2. Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, strep throat
    3. Surgical Hx; procedures, dates, inpatient or outpatient
    4. Obstetric HX: Number of pregnancies, term deliveries, preterm births, abortions

(spontaneous or induced), number of children living

  1. Immunizations
  2. Psychiatric Hx: childhood and adult (treated or hx of)
  3. Allergies: Medications, food, inhalants or other (what occurs with reaction)
  4. Current Medications: Include all prescription, herbal/supplements and OTC, dosage, frequency
  5. Last Examination Date: Physical, eye exam, foot exam, dental exam, hearing screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood, prostate, PSA, UA, TB skin test; other health maintenance tests for infants/children may include sickle-cell, PKU, lead level, and hematocrit


  1. Family History list FHx
    1. Include parents, grandparents, spouse, and children.
    2. Health conditions, familial and communicable diseases/illnesses
    3. Note whether family member deceased or living
    4. Life style patterns
    5. Immigrant status
    6. Spiritual resources/religion
    7. Health perception
    8. Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type
    9. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence
    10. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins
    11. Occupational health: Known exposure to environmental toxins at work
    12. Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook)
    13. Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family
    14. Cognitive function: Memory; speech; judgment; senses
    15. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep
    16. Exercise patterns: Type and frequency
    17. Hobbies/recreation: Leisure activities; any travel outside of the US
    18. Social habits: Tobacco; alcohol; street drug use
    19. Intimate partner violence (review screening questions on page 58 in the Jarvis textbook)
    20. Coping/stress management: Any major life change in past 2 years; do you feel tense; source; what helps
    21. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function

III. Review of Symptoms


  Symptoms to Inquire About

(please see page 54–56 in Jarvis textbook)

Document pertinent negatives and/or positives

The first system is addressed to provide a guide

General Wgt Δ; weakness; fatigue; fevers


Pertinent negatives: No weight gain or losses; no weaknesses, fatigue, or fevers

Pertinent positives: Positive weight gain over past 2 months with fatigue and weakness; no fevers

Skin Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails  
Head Headache; head injury; dizziness or vertigo  


Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma  
Ears Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use  


Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain  


Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste  
Neck Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion  
Breasts Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area  
Pulmonary Cough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest x-ray, TB skin test  
Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD  
G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance  
GU Frequency; nocturia; urgency; dysuria; hematuria; incontinence

Females: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps; menopause; hot flashes; post-menopausal bleeding;

Males: Caliber of urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often

Peripheral Vascular Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers  
Musculo-skeletal Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease  
Neuro Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations  
Heme Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation  
Endo Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distribution  
Psych Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses  

MN552 Advanced Health Assessment Unit 2 Documenting Subjective Information.