The Patient Who Came for Her Husband: A Comprehensive Health History of a 61-Year-Old Caregiver, With the Sensitive Questions Asked and Recorded
[Student Name]
University of Phoenix
NSG/502: Pathophysiology, Assessment Variables and Pharmacology II
Week 1 Assignment
[Instructor Name]
[Date]
The patient and all history details are a composite written for a model paper.
Identifying Data and Source
Mrs. A. B. is a 61-year-old married woman, a retired bookkeeper, seen as a new patient in a primary care clinic. History obtained from the patient, who gave a clear, consistent account, in a private exam room; her husband, who has moderate Alzheimer's dementia, waited in the lobby with a volunteer.
Chief Concern
"I'm here because my daughter made me come. I'm tired all the time."
History of Present Illness
Mrs. B. reports fatigue that began about eight months ago and has worsened over the past three. She describes it as "no energy by noon" rather than sleepiness. She sleeps about five hours a night in broken periods, because her husband wanders after midnight two or three times a week and she gets up to redirect him. She naps briefly on some afternoons without feeling rested. She denies fever, night sweats, weight loss, shortness of breath, chest pain or changes in bowel habits. She has noticed headaches at the end of the day, relieved by acetaminophen, which she takes about four times a week. She has not tried anything else for the fatigue and "didn't think it was worth a doctor's time."
Past Medical and Surgical History
High blood pressure since age 54. Hypothyroidism diagnosed at 48. Cholecystectomy at 39. Two vaginal births. No hospitalizations in the past ten years.
Medications and Allergies
Lisinopril 10 mg daily; levothyroxine 88 mcg daily, which she admits she often takes with her morning coffee; acetaminophen 500 mg as needed. No supplements. Allergy: sulfonamides cause a rash.
Family History
Mother: hypertension, died at 82 of stroke. Father: type 2 diabetes, coronary artery disease, died at 70 of myocardial infarction. One sister, 58, with depression treated with medication. Two adult children, healthy.
Personal and Social History
Mrs. B. has been married 38 years and has cared for her husband since his diagnosis four years ago. She manages his medications, meals, bathing and appointments. Her daughter lives 40 minutes away and visits on weekends. She stopped attending her church choir two years ago because she "couldn't leave him."
Alcohol: after a brief explanation that she would be asked about alcohol as every patient is, she completed the AUDIT-C, reporting a drink four or more times a week, usually two glasses of wine in the evening "to switch off," and no occasions of six or more drinks. Her score of 5 is positive for women at a threshold of 3 or more (Bush et al., 1998).
Tobacco and other substances: never smoked; no other substances.
Diet: skips lunch most days; dinner is often what her husband will eat.
Exercise: none, beyond housework.
Safety: she feels safe at home. When asked directly, she said her husband has pushed her twice when agitated in the evening, without injury. She has no firearms in the home.
Sexual health: not sexually active for two years; no concerns she wishes to discuss.
Mood: she described feeling "flat" most days and "guilty for being angry with him." On the two-question screen, she answered yes to depressed mood and loss of interest, and the PHQ-9 gave a score of 11, in the moderate range (Kroenke et al., 2001). She denied thoughts of harming herself.
Health Maintenance
Last mammogram three years ago; last colonoscopy at 52, normal; no bone density scan; influenza vaccine last year; no dental visit in two years.
Review of Systems
General: tiredness as described; no weight change. Skin: dry skin. HEENT: occasional headaches; no vision change. Cardiovascular: no chest pain or palpitations. Respiratory: no cough or dyspnea. Gastrointestinal: no pain, bleeding or change in habits. Genitourinary: nocturia once a night. Musculoskeletal: low back pain after helping her husband in the shower. Neurological: no weakness or numbness. Psychiatric: low mood and guilt as above; no hallucinations. Endocrine: feels cold more than others. Hematologic: no easy bruising.
Commentary on the Interview
The interview shows why a comprehensive history cannot stop at the chief concern. Mrs. B. named fatigue, but the history found at least five possible contributors: broken sleep, moderate depressive symptoms, alcohol use above recommended limits, hypothyroidism that may be undertreated because her levothyroxine is taken with coffee and a caregiving load that has removed her from her social supports. The physical examination and laboratory tests will help separate these, but the history is where most of the diagnostic work happens (Bickley et al., 2021).
The sensitive questions were asked in a particular way. They came after rapport was established, in the private part of the visit with her husband outside, and each was introduced with a short explanation that the question is routine. Validated tools, the AUDIT-C and the PHQ-9, were used so that results could be measured and compared later rather than recorded as impressions. The question about being hurt at home was asked plainly and directly, because caregivers of people with dementia can be harmed by the person they care for and are unlikely to raise it themselves. Her answer does not mean she is in danger tonight, but it belongs in the record and in the plan.
Nonverbal cues also mattered. She became tearful when describing the choir she left and apologized for "complaining." The interviewer paused, acknowledged her feelings and did not rush to reassure, which allowed her to add the detail about guilt and anger that led to the depression screen.
How the History Shapes the Examination
A comprehensive history also tells the examiner where to look. Because of Mrs. B.'s fatigue, feeling cold and dry skin, the examination should include careful attention to the thyroid, the skin, hair and reflexes, since undertreated hypothyroidism can cause each of these findings. Her low back pain after helping her husband shower calls for a focused back examination and a question about lifting technique. Her alcohol use and depression screen call for an assessment of mood, affect and thought content during the examination and a check of blood pressure, which alcohol can raise. Her report of being pushed calls for a gentle look for bruises on her arms and trunk, explained to her as part of a routine skin examination. None of these would be prompted by the chief concern of fatigue alone. The history, in other words, turns a general examination into a targeted one, which is why the course places it first.
Life-Span Considerations
At 61, Mrs. B. sits between midlife and older adulthood, and the history reflects both. She is young enough that her caregiving role may last many years, and old enough that health maintenance items such as bone density, colon cancer screening and shingles vaccination now apply. A history taken from a 25-year-old would spend more time on reproductive health and injury risk, and one from an 85-year-old more on function, falls and memory.
Summary
Mrs. A. B. is a 61-year-old caregiver presenting with eight months of fatigue in the setting of fragmented sleep, a positive depression screen with a PHQ-9 score of 11, a positive AUDIT-C, hypothyroidism with a medication-timing problem, occasional aggression from her husband and loss of social support. The physical examination, thyroid-stimulating hormone and basic laboratory tests are the next steps, along with a conversation about respite services and caregiver support.
References
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.
Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789-1795. https://doi.org/10.1001/archinte.158.16.1789
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
How this NSG 502 Week 1 example is structured
The NSG/502 description covers performing and documenting comprehensive health assessments, and many sections begin with the health history and interviewing. This sample is written as a clinical document with the standard sections of a comprehensive history, followed by a commentary on interviewing technique, so both the product and the method are visible. Students search this week as NSG 502 Week 1, NSG502 Wk 1 or NSG/502 Wk 1; all three are the same assignment.
NSG/502 Week 1 questions, answered
What does NSG/502 Week 1 usually ask for?
The course description centers on performing and documenting comprehensive health assessments, and many sections begin with the comprehensive health history and interviewing techniques, including sensitive topics.
What are the parts of a comprehensive health history?
Identifying data and source, chief concern, history of present illness, past medical and surgical history, medications and allergies, family history, personal and social history, health maintenance and a review of systems.
How should sensitive questions be asked?
With privacy, a brief explanation that the questions are asked of every patient, neutral wording, a validated screening tool where one exists and no judgment in voice or record.
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