NR 305 Week 2 Health History Write-Up Example

Health History of a 47-Year-Old Line Cook Reporting Six Weeks of Hoarseness

Student Name

College of Nursing, Chamberlain University

NR 305: Health Assessment for the Practicing RN

Instructor Name

Month Day, Year

Health History of a 47-Year-Old Line Cook Reporting Six Weeks of Hoarseness

Biographical Data and Source

Person: Ms. R., a 47-year-old woman, cooks on the hot line of a busy restaurant, mostly evenings and weekends.

Source and reliability: Ms. R. herself, who agreed to the interview for this assignment. She answered readily, gave consistent dates and consulted her phone calendar for two of them. Everything below is her report; no examination or records were reviewed.

Setting: A private room at the writer's workplace, on a weekday afternoon, lasting about 50 minutes.

Reason for Seeking Care

In Ms. R.'s words: My voice has been rough for six weeks and it is not coming back. By the end of a shift I can hardly call orders.

History of Present Illness

Ms. R. reports that her voice became hoarse about six weeks ago, after a cold that otherwise cleared within a week. She describes her voice as rough and breathy, better in the morning and worse by the end of an evening shift, when she has to shout orders over the kitchen noise and the hood fans. She rates the effort of speaking as 3 out of 10 in the morning and 7 out of 10 by midnight. She reports a constant urge to clear her throat and a feeling of a lump in her throat that does not interfere with swallowing. She reports heartburn two or three nights a week after eating her one main meal late, around midnight, and that she sometimes wakes with a sour taste. She reports no difficulty or pain with swallowing, no coughing up blood, no weight loss she has noticed and no lump in her neck that she can feel. Resting her voice on her two days off helps somewhat. She has tried throat lozenges and hot tea with honey, which soothe but do not change the hoarseness. She was a smoker between 18 and 35, about twenty cigarettes daily, and stopped 12 years ago. She is worried because a coworker's father had throat cancer. The account above follows the standard attributes of a symptom, from when and how it began through what makes it better or worse and how severe it is, as health assessment texts recommend for a presenting concern (Jarvis & Eckhardt, 2024).

Past Health History

Childhood illnesses: Chickenpox as a child; she does not recall others.

Adult illnesses: High blood pressure diagnosed about five years ago, which she says is controlled. No asthma, diabetes or thyroid disease that she knows of.

Surgeries and hospitalizations: Appendectomy at about age 20; two vaginal births, at ages 24 and 28; no other hospital stays.

Injuries: A burn on her left forearm from a fryer about ten years ago, treated in an urgent care clinic.

Immunizations: She believes she had a tetanus shot after the burn and a flu shot two years ago; she does not know her other vaccinations.

Last screenings: She reports her last Pap test and mammogram were about four years ago and that she has not had a colonoscopy.

Medications and Allergies

Medications: Lisinopril 10 milligrams by mouth once daily; an over-the-counter antacid, chewable, two or three nights a week; no inhalers, supplements or herbal products.

Allergies: Sulfa antibiotics, which she says gave her a rash with hives in her twenties. She knows of no food or latex allergies.

Family History

Mother: Age 71, living, with high blood pressure and type 2 diabetes.

Father: Died in his late sixties after a heart attack, according to Ms. R.

Sister: Age 51, living, with acid reflux treated with a daily pill.

Brother: Age 44, living and well as far as she knows.

Children: Two sons, 23 and 19, both well.

She reports no known family history of head, neck or lung cancers.

Review of Systems

General: Tired after long shifts, which she attributes to her hours; no weight change that she has noticed; no fevers or night sweats.

Skin, hair and nails: No rashes or sores; small healed burn scars on both forearms from work.

Head, eyes, ears, nose, throat: Hoarseness, throat clearing and lump sensation as above; a stuffy nose most mornings; no ear pain, no sore throat, no mouth sores.

Respiratory: Occasional dry cough, worse in the kitchen; no shortness of breath, no wheezing, no blood in sputum.

Cardiovascular: No chest pain, no palpitations, no leg swelling.

Gastrointestinal: Heartburn and sour taste as above; no difficulty swallowing; regular bowel movements with no blood.

Genitourinary and reproductive: Regular menstrual periods; no urinary symptoms.

Musculoskeletal: Low back pain after long shifts, relieved by ibuprofen and rest.

Neurologic: No numbness, weakness, dizziness or changes in vision.

Psychiatric: She describes herself as stressed by work hours but denies feeling sad most days or losing interest in things she enjoys.

Endocrine: No heat or cold intolerance; no excessive thirst.

Hematologic: No easy bruising or swollen glands that she has noticed.

Functional Health and Lifestyle

Ms. R. reports sleeping about six hours on work nights, going to bed around 0100 after late shifts. She eats one main meal a day, usually around midnight after her shift, and lies down within an hour of eating. Her usual drinks are coffee, three or four cups daily, and a beer or two on her days off; her smoking history is described above. Her exercise is her work, which involves standing for eight to ten hours. She lives with her younger son and supports him financially. She has health insurance through her employer but says she avoids appointments because taking time off costs her wages. She identifies her main strength as her family and her main worry as being too tired to keep working the extra shift she needs.

Summary of the Reported History

The history records six weeks of persistent hoarseness following an upper respiratory infection in a 47-year-old woman whose work requires shouting over noise in a smoky kitchen, with reported throat clearing, a lump sensation without difficulty swallowing, frequent late-night heartburn, a former smoking history of about 17 pack-years and a worry about cancer. She reports no difficulty swallowing, no blood in sputum, no weight loss and no neck lump. The history points to where the physical examination should focus, including the head and neck, the lymph nodes of the neck, the mouth and throat and the lungs. Consistent with the approach to history taking described by Bickley et al. (2021) and Ball et al. (2023), no conclusions are drawn here: the history is the person's account, and interpretation belongs after the examination and any referral.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.