Comprehensive Health History of a 29-Year-Old Line Cook With Recurring Upper Abdominal Pain
Student Name
American College of Education
NUR4033: Health Assessment
Module 1 Assignment
Instructor Name
March 2, 2026
Identifying Data and Chief Complaint
The client, 29, cooks on the line full time at a busy downtown restaurant and lives with a roommate in a rented apartment. He came to a walk-in primary care clinic on a weekday afternoon and was the source of his own history, which appeared reliable once the interview was under way. Both the client and the clinic are invented composites for this assignment; no real person or record is described. His chief complaint, in his words, was a burning pain up high in the stomach that keeps coming back.
History of present illness. The pain began about three months ago and has become more frequent over the past three weeks. It is located in the epigastric area just below the sternum, does not radiate and is described as burning. At its worst he rates it 5 on a 10-point scale. It occurs most days, usually two to three hours after a meal and sometimes wakes him around 0200. Eating a small amount of bread or drinking milk relieves it for about an hour; lying flat after a late shift makes it worse. He has tried an over-the-counter antacid about four times a week with partial relief. He denies vomiting, blood in vomit, black or tarry stools, difficulty swallowing and unintended weight loss, and he reports no fever. The timing, the nocturnal waking and the relief with food form a pattern worth recording in the client's own sequence before any interpretation is attached to it.
Past History, Medications and Family History
Past health history. He had a fractured left wrist at age 16, treated with a cast. He has had no surgeries and no hospital admissions. He reports low back pain for about a year from long hours standing and lifting stock pots, for which he has not seen a clinician. Immunizations are reported as complete in childhood; he does not recall a tetanus booster since high school and has not had an influenza vaccine this season. He reports no known drug allergies.
Medications. At first he reported taking no medications. When asked specifically about anything he takes for pain, even from a store, he said that he takes ibuprofen most days for his back, usually two 200 mg tablets at the start of a shift and two more partway through, and sometimes four tablets at once on long weekend shifts. That amounts to 800 to 1,200 mg on a typical workday, on five or six days a week, for most of the past year. He also uses the antacid described above and takes no supplements.
Family history. His father, 58, has hypertension and had a peptic ulcer treated about fifteen years ago. His mother, 55, has type 2 diabetes. A paternal uncle died of liver disease in his fifties, which the client attributed to heavy drinking. He has one younger sister, 25, who is healthy. There is no known family history of stomach or colon cancer.
Personal and Social History and Review of Systems
Personal and social history. He works ten-hour shifts five to six days a week, usually from 1400 to midnight, and eats his main meal after midnight. Coffee runs to three or four cups daily. He has smoked roughly ten cigarettes daily for eleven years. His alcohol history is described in detail in the next section; in summary, he drinks four to five beers after most shifts and more on his days off. He denies other substance use. He is not in a relationship, reports good support from his sister and a coworker, and says his stress is mostly about money and work hours. He has employer health coverage that he has used twice.
Review of systems. General: reports fatigue on days off; denies fever, night sweats and weight change. Skin: no rashes or jaundice. Head, eyes, ears, nose and throat: no concerns. Respiratory: morning cough without blood, which he links to smoking; no shortness of breath. Cardiovascular: no chest pain with exertion, palpitations or swelling. Gastrointestinal: as in the history of present illness; bowel movements daily and formed; denies diarrhea and constipation. Genitourinary: no concerns. Musculoskeletal: low back ache at the end of shifts without leg numbness or weakness. Neurologic: occasional headaches on days after heavy drinking. Psychiatric: reports feeling irritable when he has not slept; denies low mood most days and denies thoughts of self-harm. Each system is documented as a statement the client made or denied, not as a finding, because a review of systems is history and not examination.
How the Interview Reached the Honest Answers
Two disclosures changed this history: the daily ibuprofen and the amount of alcohol. Neither appeared in response to the first question. When asked whether he drank alcohol, the client said he had a few beers now and then. That answer is common and is not necessarily an attempt to mislead; many people use general terms for amounts they have never counted. The interviewer responded without comment and moved to specific, normalizing questions: many people who work late restaurant shifts wind down with a drink after closing, and how many drinks would he have on a typical night after work? He answered four or five. He was then asked the three questions of the AUDIT-C, which asks how often a person drinks, how many drinks on a typical drinking day and how often six or more drinks are consumed on one occasion (Bush et al., 1998). His answers gave a score of 9 out of 12, well above the threshold usually used to identify unhealthy drinking in men.
The medication disclosure followed the same logic. Asking whether a client takes any medications often yields only prescriptions, because people do not think of over-the-counter pills as medicine. A more specific question about anything taken for pain, including from a store, prompted the ibuprofen history immediately. Jarvis and Eckhardt (2024) recommend open-ended questions followed by focused ones for exactly this reason: the open question invites the client's story, and the focused question fills the gaps the client does not know are important.
The tone of the interview mattered as much as the wording. Miller and Rollnick (2013) describe how a nonjudgmental, curious stance makes people more willing to talk about behaviors they expect to be criticized for. The interviewer did not react to the amount of alcohol, did not lecture about ibuprofen and summarized what she had heard before moving on, which gave the client a chance to correct anything that was wrong. An accurate history is not extracted from a client; it is offered by one who has decided the interviewer can be trusted with it. The United States Preventive Services Task Force recommends screening adults in primary care for unhealthy alcohol use and offering brief counseling to those who screen positive (U.S. Preventive Services Task Force [USPSTF], 2018), and the AUDIT-C result from this interview makes that counseling possible at the next step of the visit.
Interpretation and Next Steps
The history points toward peptic ulcer disease or erosive gastritis as the leading working concern. Burning epigastric pain that occurs hours after meals, wakes the client at night and is relieved by food and antacids fits that pattern, and the history contains several risk factors together: daily nonsteroidal anti-inflammatory drug use at a substantial dose for most of a year, heavy alcohol use, smoking, late-night meals and a father with a treated ulcer. Gastroesophageal reflux disease remains possible given the worsening when lying flat after late meals. No alarm features were reported, but the reliance on self-report means they must be confirmed on examination and, where appropriate, with testing.
The history also shapes the physical examination that follows. The examination should include vital signs with attention to heart rate and orthostatic changes, an abdominal examination for epigastric tenderness, guarding and liver size, inspection of the skin and conjunctivae for pallor, and a check for signs of chronic alcohol use. The findings will be reported to the nurse practitioner along with a recommendation to discuss stopping or replacing the ibuprofen, testing for Helicobacter pylori and a brief alcohol intervention during this visit. A health history is complete when it leads somewhere, and this one leads to three concrete decisions.
References
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
Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
U.S. Preventive Services Task Force. (2018). Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA, 320(18), 1899-1909. https://doi.org/10.1001/jama.2018.16789
How this NUR 4033 Module 1 example is structured
NUR 4033 Module 1 often builds the health history and the communication that earns an honest answer; your classroom's instructions decide whether the deliverable is a full history, a focused one or an interview reflection. This example follows the standard order of a comprehensive history, from identifying data and chief complaint through the review of systems, so a grader can find each component where it is expected. A separate section then explains the communication choices behind the two most important disclosures, and a short interpretation closes the paper by naming the working concerns and what the history adds to the examination that follows.
NUR4033 Module 1 questions, answered
What does NUR4033 Module 1 usually ask for?
NUR4033 Module 1 often centers on the health history and the communication skills needed to obtain it. Many sections ask for a written comprehensive or focused history on a volunteer or a composite client, sometimes with a reflection on the interview. Your classroom's instructions decide the format, which components are required and whether a recorded interview is involved.
How do I write a history of present illness that scores well?
Cover onset, location, duration, character, aggravating and relieving factors, radiation, timing and severity, and record the client's own words for the main complaint. Add pertinent negatives, the symptoms you asked about that the client denied, because they show clinical reasoning. Keep interpretation out of the history section itself and place it in a separate conclusion.
Should a history paper explain how the interview was conducted?
If the rubric includes communication, yes. Describe the questions that produced important disclosures, such as a specific question about over-the-counter pain relievers, and cite a source for the technique. Showing how you obtained accurate information is often what separates a strong Module 1 paper from a correct but mechanical history.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official American College of Education document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.