Assignment: Digital Clinical Experience (DCE): Health History Assessment

Assignment: Digital Clinical Experience (DCE): Health History Assessment

The patient was brought into the unit by his relatives. He was brought with complains of difficulty in breathing.

Demographic Data

The patient is a 37-year old married, African-American male. He is married with two children. He works in a chemical production company as a manager. He is a Christian who attends church on a regular basis. He lives with his wife and two children and reports that they are the source of his strength. The client’s highest level of education is university. He studied bachelor’s degree in commerce and accounting.

Reason for Care

The patient was brought in with complains of difficulty in breathing. The client and his significant others reported that the patient has chest pains and tightness. He also feels easily fatigued. There is also wheezing on expiration. The client also reported some productive cough during the episodes of the above symptoms.

Present Illness

The patient reported that the symptoms started two days ago. He took over the counter medications as he thought it was flu. However, the symptoms did not improve resulting in him seeking for further care in the hospital. He reports that the symptoms worsen when he is in his workplace. He further reported that analgesics such as acetaminophen have been ineffective in relieving the above symptoms.

Perception of Health

The patient reported to be an active seeker of health services. He usually attends screening clinic for health problems such as diabetes and hypertension. He has also been screened for prostate cancer, which came out negative. His family also often undergoes medical checkup twice a year. He reported that his health is his responsibility.

Past Medical History

The client has two histories of hospital admissions. He was first admitted in the hospital when he was 17 years due to pneumonia. He was also admitted to the hospital when he was 26 years due to meningitis. He does not have any history of surgery. He also does not have a history of blood transfusion or known allergies to drugs and food. He also does not have a history of allergic reaction to any environmental irritants.

Family Medical History

There is history of diabetes and hypertension in the family. The client’s mother was diagnosed with diabetes while his father has hypertension. They are both deceased.

Review of Systems

Vital signs: temperature 37.8 (degrees Celsius), BP 124/86, P-101, RR-26 b/min, SPO2- 90%, weight 102kgs

Cardiovascular: The patient reported chest pain. There were palpitations and dyspnea.

Respiratory: There was shortness of breath, nasal flaring, wheezing on expiration, productive cough, and chest tightness.

Gastrointestinal:  The patient denied heartburn, reflux, nausea, vomiting, constipation, diarrhea, and bleeding.

Genitourinary: the patient denied stones, flank pain, dysuria, and sexual dysfunction.

Integumentary: Patient denied any lesions

Musculoskeletal: there was normal muscle strength, no wasting, and absence of any spinal deformities.

Neurological: the patient denied headaches, balance problems, loss of consciousness or memory loss.

Endocrine: the patient denied history of diabetes, obesity, and sensitivity to cold and heat.

Developmental Considerations

The client’s development was as per his age. He received all immunizations as expected. He also performed his social and occupational roles as expected.

Cultural Considerations

The client is an African-American. He believes that health problems can be managed effectively using medicines and alternate and complementary treatments. He also believes that God has control over his health. He thinks that the treatment will assist in the realization of God’s purpose in his recovery from the disease.

Psychosocial Considerations

The patient perceives that he has optimum support from his family. He considers his family the most effective source of strength. The client does not have any history of mental health problems. It became evident from the assessment that he has effective mechanisms to handle his stressors. He has a healthy balance for his workplace and family demands. He also has social support from his friends and church members.

Collaborative Resources

As shown above, the patient has strong support from his family. He believes that his family is the source of his strength. He also has strong social support from the church members. He reported that church members have been helpful for his spiritual and emotional strength. The client also has adequate support from his friends. He reported that he always gets help he needs from his friends. The patient also has access to the healthcare he needs. He has a medical insurance coverage, which enhances his ability to access the health care that he needs. Therefore, it is anticipated that the patient’s ability to manage his health problem will be enhanced due to the readily available support resources in his community.

Objective Data

Physical Examination

General Appearance: the patient was well dressed for the occasion. He appeared to have respiratory distress. He was aware of place, time, and self.

Vital signs: temperature 37.8 (degrees Celsius), BP 124/86, P-101, RR-26 b/min, SPO2- 90%, weight 102kgs

Skin: the skin was well moist, capillary refill of less than 2 seconds, and normal skin turgor. There was no swollen lymph nodes, bleeding or skin breakages.

Head: there was hydrocephaly or anencephaly, normal distribution of hair, absence of endostoses and head scars.

Eyes: there was normal visual acuity, absence of eye discharge, and patient not using glasses.

Ear: absence of ear drainage, normal location, and air and bone conduction

Nose: presence of flaring and absence of nasal polyps

Throat: absence of nodules and inflammation noted. Mucosa, gag reflex, and tongue appeared normal.

Neck: patient can move in a range of motions, normal length of the neck, absence of trachea tenderness or deviation and nodes. Normal jugular vein pressure

Thorax:  tachypnea noted. Absence of retractions, barrel chest, and prolonged expiratory phase

Lungs: presence of wheezes on expiration noted. Absence of stridor and rhonchi noted.

Breast: no abnormality detected.

Back: absence of spinal bifida or misalignment of the spinal cord noted.

Abdomen: absence of abdominal tenderness, inflammation or hernias noted. Presence of normal bowel movements on auscultation

Extremities: absence of peripheral cyanosis, fractures and extra digits with normal muscle tone and movements in a range of motions

Genitalia: not indicated

Neurological: absence of confusion, loss of consciousness, or weak muscle tone and activity

Needs Assessment

The above health assessment led to the identification of a number of health educational needs for the patient. One of them was the need for health education targeting healthy lifestyle (de Oliveira Otto et al., 2018). The assessment findings revealed that the patient was overweight. It was therefore important that the patient be educated on the health risks of overweight and obesity and strategies to achieve healthy weight. Evidence has consistently revealed that overweight and obesity increase the risk of health problems such as cardiovascular diseases, diabetes, and cancer (Karsten et al., 2019). Patients are highly at a risk of developing cardiovascular diseases such as hypertension and heart attack. The patients are also likely to develop diabetes due to high insulin resistance. There is also the increased risk of some cancers with obesity and overweight. The patient should therefore be informed about these risks for him to adopt the recommended strategies for healthy weight gain. The patient also needs to be educated on the importance of engaging in active physical exercises and eating healthy diets to promote healthy weight gain. The patient should be educated on the health risks of sedentary lifestyles too (Lv et al., 2017). Therefore, it is anticipated that providing health education on these aspects of health will promote healthy lifestyle and behavioral change in the patient.

The above assessment findings pointed towards a possible diagnosis of asthmatic attack for the patient. It is therefore important that the patient be provided with health education on the effective management of the disease. One of the areas that relate to asthma management that the patient should be educated is the triggers of asthma attacks. The patient should be educated on the need to avoid environmental triggers such as dust, chemicals, pollen, and excessive exercise. The patient should also be educated on the importance of wearing protecting gears such as facemasks in his workplace to prevent incidences of asthmatic attacks (Chen, Wong & Li, 2016). The patient also needs health education on the importance of adherence to medications. Effective management of asthma is highly dependent on the manner in which the patient adheres to the treatment and the recommended lifestyle and behavioral interventions. Treatment adherence prevents relapse of symptoms and development of severe form of asthma that is unresponsive to treatment. Effective management of the disease will also prevent other complications such as remodeling of the airways (George & Bender, 2019). Therefore, it is essential that the patient be educated on the need for treatment adherence for optimum outcomes of the disease management.


In my view, the assessment of this client was successful. The success was attributed to the active involvement of the patient and his significant others in the assessment of his health problems and ways of addressing it. Effective communication enabled the active engagement between the patient and I. I employed the use of interviewing skills such as active listening, maintaining eye contact, asking open-ended questions, and reframing to obtain adequate data from the client. The experience provided me with significant insights into the ways of performing subject and objective assessment of the patients. It made me understand the influence of environment on patient-provider interaction. The environment should promote privacy to enable the clients to express their health problems without fear. The healthcare provider should also build trust with the patient, as a way of obtaining adequate subjective data from the patient.

One of the things that went well is the active involvement of the patient. The patient and his significant others were highly involved in the assessment, planning, and implementation of the care that was needed for recovery. The other thing that went well was the acquisition of objective data from the patient. I was able to obtain all the objective data from the patient in a chronological manner to enable me develop an accurate diagnosis for his condition. One of the barriers that I encountered during the assessment was reluctance of the patient to provide some of the information related to his health problem. The reluctance was due to the presence of his children during the interaction. I addressed this issue by requesting them to leave the patient and his wife in the examination room.

I will therefore adopt a number of interventions during my next clinical encounter. Firstly, I will aim at making the patient feel comfortable as possible for me to obtain detailed data about the health problem. I will use approaches such as establishing rapport with the patients and assuring them about the integrity of their information for them to play an active role in the process of healthcare. I will also consider incorporating the use of visuals in explaining a disease process and management to the patient. I will use the visuals that have been developed for specific health problems to increase the understanding of the patients about the management of the disease. Through this, I believe that I will be able to perform comprehensive patient assessment that will inform sound decision-making in the planning of care that the patients need.




Chen, Y., Wong, G. W., & Li, J. (2016). Environmental exposure and genetic predisposition as risk factors for asthma in China. Allergy, asthma & immunology research8(2), 92-100.

de Oliveira Otto, M. C., Anderson, C. A. M., Dearborn, J. L., Ferranti, E. P., Mozaffarian, D., Rao, G., … & Lichtenstein, A. H. (2018). on behalf of the American Heart Association Behavioral Change for Improving Health Factors Committee of the Council on Lifestyle and Cardiometabolic Health and Council on Epidemiology and Prevention; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Stroke Council. Dietary diversity: implications for obesity prevention in adult populations: a science advisory from the American Heart Association [published online ahead of print August 9, 2018]. Circulation.

George, M., & Bender, B. (2019). New insights to improve treatment adherence in asthma and COPD. Patient preference and adherence13, 1325.

Karsten, M. D., van Oers, A. M., Groen, H., Mutsaerts, M. A., van Poppel, M. N., Geelen, A., … & Hoek, A. (2019). Determinants of successful lifestyle change during a 6-month preconception lifestyle intervention in women with obesity and infertility. European journal of nutrition58(6), 2463-2475.

Lv, N., Azar, K. M., Rosas, L. G., Wulfovich, S., Xiao, L., & Ma, J. (2017). Behavioral lifestyle interventions for moderate and severe obesity: a systematic review. Preventive medicine100, 180-193.

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