Milestone #1 Form for Health History essay

BIOGRAPHICAL DATA (10 pts)

26-may-2016

Initials:

O m

Age:

43

Date of birth:

20^th February 1973

Birthplace:

Chicago

Gender:

Male

Marital status:

Married

Race:

White

Religion:

Christian

Occupation:

Restaurant manager

Health insurance:

David insurance

Source of information:

The patient competently provided the information required during the Interview. He gave the data clearly and confidently

Reliability information source:

He was able to articulate the information clearly and comprehensively. The information provided was reliable.

PRESENT HEALTH HISTORY/ILLNESS (15 pts)

Reason for seeking care:

Chest pains for 3 hours, restlessness all day, He wants to begin exercising and requires check up.

Health patterns:

`The patient was in a poor health state until four days ago. During that period he had SOB with stiffness in the chest. To make breathing easier he has been using albuterol MDI 2 inhalation qid. Yesterday he had a sore throat, fatigue, sputum, nasal discharge and a body temperature of 37.2⁰C. The symptoms started the day after he carried out yard work.

Health goals:

He wants to be health so that he can play well his managerial role and also carry out exercises

HEALTH BELIEFS AND PRACTICES (15 pts)

Beliefs and practices:

He believed in blessings before a surgery. If he is sick he believed that he should be offered sacraments. He would also request holy communion prior surgery. He also believes that stray cats cause diseases

healthcare decisions influencing Factors:

Food belief and diet, beliefs about causes of illness, views on health.

Related traits, habits or acts:

He believed that injections work better than oral medicine.

MEDICATIONS (15 pts)

Prescription medications:

One week ago he received medications on severe headaches and tooth aches.

Over-the-counter medications:

He received OTC medications to control headaches and toothaches.

Herbals:

He used herbal medicine to calm the tooth ache pains

PAST HISTORY (15 pts)

Childhood diseases:

He suffered from common diseases such as common cold. He did not suffer from any major childhood disease

Immunizations:

BCG at birth, DPT, OPV, AMV, TT, HBV, Influenza vaccine.

Allergies:

Food- allergic to red meat.

Drugs- catecholamic drugs,

Environmental allergens- not allergic to any environmental allergens.

Blood transfusions:

He has never transfused blood

Major illnesses:

Suffered no major illness

Injuries:

Suffered only minor back injuries after he fell in his compound

Hospitalizations:

The patient has never been hospitalized

Labor and deliveries:

Not applicable

Surgeries:

No surgeries ever carried out on the patient

Use of alcohol:

He is an alcoholic and drinks every weekend. He was also diagnosed with cirrhosis

Use of tobacco:

The patient does not use tobacco

Use of illicit drugs:

He uses no illicit drug

EMOTIONAL HISTORY (15 pts)

Mental, psychiatric, or emotional problems:

He has not suffered any psychiatric conditions, from his lineage there is no trace mental illness condition

FAMILY HISTORY (15 pts)

(Duraiswamy et al, 2011)

Father:

Died at the age of 68 years.

Cause of death- high blood pressure.

Mother:

Aged 64 years.

Health condition-she is in good health condition but for last one year she has been suffering from asthma

Siblings:

Aged 34 years.

Health status-he is in a healthy body status.

Grandparents:

Died at the age of 76 due to blood pressure

PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts)

(Basham et al, 2016)

Occupational history:

The patient began his career as a restaurant attendant he was later promoted to an assistant manager at the restaurant. Due to outstanding performance as an assistant manager he was promoted to be the manager.

Educational level:

Highest level of education was the college level.

Financial background:

He is a middle class income earner, living an average life.

ROLES AND RELATIONSHIPS (15 pts)

(Barnett et al, 2012)

Significant others:

Has close relationship ties with his family and he is the sole bread winner.

Support systems:

All support system functioning normally.

ETHNICITY AND CULTURE (10 pts)

Ethnicity and culture:

He is not affiliated to any ethical group. He does not have strong ties held to culture.

social and Physical characteristics influencing healthcare decisions:

Poverty, discrimination, healthy food, social exclusion or isolation.

SPIRITUALITY (5 pts)

spiritual and Religious needs:

Believes in blessings. Before any operation or surgery there must be a holy communion.

SELF-CONCEPT (5 pts)

View of self-worth:

He is worth to the society and believes in himself. Ambitious and outstanding.

Future plans:

He aims at establishing his own restaurant. Venture in business and become more successful in life. He also aims at having a full medical cover.

REVIEW OF SYSTEMS (20 pts)

(Jarvis, 2016).

hair Skin, nails:

Skin lesions, changes in hair texture, nails change in color and brittleness.

neck, Head and related lymphatics:

Severe headache, dizziness, swollen neck.

Eyes:

Change in vision, blurred vision.

Ears, mouth , throat and nose:

Sore throats, bleeding gums, in the ears otorrhea.

Respiratory:

Emphysema, chest pains, noisy breathing.

Breasts and axillae:

Pain, rashes.

Cardiovascular:

Retrosternal pain, dyspnea on exertion, hypertension.

Peripheral vascular:

Swelling of legs, discoloration of hand or feet.

Abdomen:

Abdominal pain, pyrosis, nausea and vomiting.

Urinary:

Dysuria, polyuria does not have any history on kidney diseases.

Reproductive:

Penile discharge, lumps and hernia.

Musculoskeletal:

Stiffness in joints, muscle pains and afternoons back pains.

Neurologic:

Sensory function-the patient has never experienced memory disorders.

Motor function- he has experienced weaknesses for the last one week and fainted once.

Milestone 1: Health History Form Rev. 10/29/14jm

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