The goal of obtaining a health history is to collect subjective data from the patient or the patient’s family so that the healthcare team and the patient can work together to create a plan that promotes health, addresses acute health problems, and minimizes chronic health conditions. The health history is typically taken upon hospital admission, but it may be taken whenever additional subjective information from the patient may help inform care (Wilson & Giddens, 2013).
The information gathered may be subjective or objective. Subjective data is information provided by the patient and may include signs and symptoms described by the patient but not observed by others. Demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history are all examples of subjective data. Objective data is information gathered by a health care professional during a physical examination and consists of information that the health care professional can see, feel, smell, or hear. The data provides a health history that allows the healthcare professional to assess health promotion practices and provide patient education (Stephen et al., 2012).
You will take on the role of a clinician who is building a health history for the following cases
Chief Complaint: A 11-year-old female patient complains of red left eye and edematous eyelids. Her mother states the child complains of “sand in my left eye.”
Subjective: Patient noticed redness three days ago. Denies having any allergies. Symptoms have gotten worse since she noticed having the problem.
Vital Signs: (T) 98.2°F; (RR) 18; (HR) 78; BP 128/82; SpO2 96% room air; weight 110 lb.
General: well-developed, healthy, 11 years old
HEENT: EYES: very red sclera with dried, crusty exudates; unable to open eyes in the morning with the left being worse than the right
Skin: CTA AP&L