Health History Taking - Nursing Interview

Summary

In this nursing interview, Shikaina Aquino, a student nurse, conducts a health history assessment with Mrs. Cherry Aquino. Mrs. Aquino, 49, seeks medical attention for a severe cough and sore throat, which have persisted for several days. During the interview, the nurse collects information on the patient's symptoms, medical history, family health background, allergies, and lifestyle factors. Vital signs and a lung examination are also performed, revealing wheezing. After consulting with a doctor, Mrs. Aquino is prescribed medication to address her symptoms and is advised to return for a follow-up in seven days.

Takeaways

• 😀 The nursing interview starts with the student nurse introducing themselves and asking for basic personal information from the patient, Mrs. Cherry Aquino.
• 😀 Mrs. Aquino is 49 years old and is experiencing severe coughing, a sore throat, and mild chest pain, which is worse at night and when coughing.
• 😀 The cough is accompanied by yellowish, sticky sputum but no blood. The patient also experiences slight difficulty in swallowing solid food.
• 😀 The pain in Mrs. Aquino's chest is described as squeezing, with a pain scale rating of 3 to 4 out of 10.
• 😀 Mrs. Aquino has no significant medical history but has an allergy to nuts, shrimp, and dogs, and her father had diabetes and high blood pressure.
• 😀 The patient has been self-medicating with carbocysteine (500 mg) and lozenges for 2 to 3 days, with no significant improvement.
• 😀 Mrs. Aquino's vital signs are within normal limits: temperature 37°C, pulse rate 70 bpm, respiration rate 16 breaths per minute, and blood pressure 120/80 mmHg.
• 😀 The nursing student hears wheezing in Mrs. Aquino's lungs during the assessment, suggesting possible respiratory issues.
• 😀 The doctor confirms the presence of wheezing and prescribes amoxicillin, mucolytics, and antihistamines to treat the infection, loosen mucus, and address allergies.
• 😀 Mrs. Aquino is advised to return for a follow-up visit in 7 days for further evaluation and management of her condition.

Q & A

What is the main health issue that brought Mrs. Cherry Aquino to the hospital?

Mrs. Cherry Aquino came to the hospital due to severe coughing, an itchy sore throat, and difficulty swallowing solid food. She also experienced slight chest pain and difficulty breathing during coughing.

How long has Mrs. Aquino been experiencing her symptoms?

Mrs. Aquino has been experiencing her symptoms, including severe coughing and sore throat, for about four to five days.

What did Mrs. Aquino describe about her cough?

Mrs. Aquino described her cough as producing yellowish, sticky phlegm, but she did not notice any blood in it.

Has Mrs. Aquino experienced any pain due to her symptoms?

Yes, Mrs. Aquino experiences a slight squeezing pain in the middle of her chest and in her throat every time she coughs.

What medications has Mrs. Aquino taken for her symptoms?

Mrs. Aquino took Carbocysteine 500 mg and Strepsils lozenges for her cough and sore throat for two to three days.

Does Mrs. Aquino have any history of chronic health conditions?

No, Mrs. Aquino has never been admitted to the hospital due to illness, and she does not have any chronic conditions like diabetes, heart disease, or asthma.

What allergies does Mrs. Aquino have?

Mrs. Aquino is allergic to nuts (such as peanuts and cashews), shrimp, and her pet dog, which triggers sneezing.

What is Mrs. Aquino’s family medical history?

Mrs. Aquino’s mother had asthma, and her father had high blood pressure and diabetes.

What lifestyle habits does Mrs. Aquino have that could affect her health?

Mrs. Aquino smokes about five cigarettes a day, though she is considering quitting. She drinks wine occasionally during special occasions and follows a mostly vegetable-based diet, often incorporating pork and chicken.

What follow-up is required for Mrs. Aquino after her visit?

Mrs. Aquino is prescribed medications to combat infection and manage her allergies. She is advised to return for a follow-up checkup after seven days.