Running head: HEALTH HISTORY AND CARE PLAN
Health History and Care Plan
Student’s Name
University Affiliation
Running head: HEALTH HISTORY AND CARE PLAN
Abstract
This paper describes the health history of a 57-year-old patient who demonstrated certain
symptoms. The patient is living with rheumatoid arthritis for 3 years. The aim of the health
history and care plan assessment on the patient is to determine and diagnose the patient of the
disease he is suffering from. A thorough assessment is performed on the patient and results are
drawn from the symptoms. A review of systems is performed on the patient and the results are
tallied. An assessment i.e. functional assessment, muscle strength, and mini-cog assessment are
done from the review of systems. Finally, a NANDA diagnosis on the primary health issue of the
patient is identified and the patient is diagnosed. A plan and intervention methods for the patient
are developed to address the primary health issue.
Running head: HEALTH HISTORY AND CARE PLAN
History
Identifying information
Born in 1963, the patient is a 57-year-old male. He is 6 feet tall and of medium build. The patient
is normal and there are no communication disabilities. The patient is well nourished and lives a
healthy life of a middle-income earner. The patient complains of frequent dizziness that leaves
him partially blind, imbalanced and lightheaded.
Problems, allergies, medications, & immunizations list
The patient started experiencing the dizziness problem earlier this year in January. By then the
patient had started experiencing other issues relating to joint pain. The patient was diagnosed
with rheumatoid arthritis 3 years ago and has been on medication ever since. Medication used as
anti-inflammatory drugs. The patient has reported improvement in his joints with noticeable
results in reduced pain. The patient has continued with the medication due to its effective
capabilities. The patient has no known allergies of any kind.
General client/ patient information
The patient lives in a high humid area where he conducts agricultural farming. The area also
experiences severe bouts of shivering cold in the winter. This could be the reason for the
aggravated rheumatoid arthritis problem. The patient complained of pain, stiffness and swollen
joints. The patient smokes and also takes alcohol on a common basis.
Source and reliability of the information
Chief concern/presenting the problem
Running head: HEALTH HISTORY AND CARE PLAN
The patient said, “I recently experienced a heavy wave of dizziness after I stood up from a
lengthy squat while working on the farm.” “I thought it was due to the long squat but the dose of
dizziness keeps on coming back making me weak.”
History of present illness
The patient has a history of rheumatoid arthritis which he was diagnosed with back in the year
2017. Although it was still in its early stages back then, the condition has continued to worsen
each day.
Since February the patient has had increased fatigue and shortness of breath. Recently, the
patient noticed dizziness which has continued to persist. During the two months even through the
use of medication, the patient has been experiencing worse symptoms of nausea, vomiting,
