Comprehensive Health History Assignment of Patient

Comprehensive Health Assessment Form Health History Biographical data: Age: 60 Marital status: Married Birth date: 07/02/1960 Number of dependents: 5 Educational level: Bachelor of Civil Engineering, University of Waterloo Gender: Male Occupation (current or, if retired, past): Civil Engineer Ethnicity/nationality: Black/African Source of history: Individual himself, seems reliable Present health history: Current medical conditions/chronic illnesses: Hypertension Current medications: Teva-Losartan (Losartan Potassium) 50mg, 1.5tab/daily. Medication/food/environmental allergies: Patient reports no known allergies Past health history Childhood illnesses: Patient had chickenpox once at the age of six, patient would get ear infections and had it treated with antibiotics prescribed by a doctor, patient had asthma at a young age and after adolescents went away. Patient denies having mumps, rubella, pertussis or throat infections. Hospitalizations/Surgeries: Patient was hospitalized once after car accident in 2001, patient has not had any surgeries. Accidents/injuries: Patient was involved in a motor vehicle accident in 2001 and states no head injuries with loss of consciousness, fractures, burns and or severe lacerations. Major diseases or illnesses: Patient states no major disease or illness such as; heat problems, cancer, seizures and only major adult illness being diagnosed with hypertension. Immunizations (dates if known): Tetanus - 01/2020 Diphtheria - 01/2020 Pertussis - 01/2020 Mumps - As a child Rubella - As a child Polio - 6 years old Hepatitis B - 7th Grade Influenza - 01/2020 Varicella - Not Known Other – N/A Recent travel/military services: Patient states no recent travel or military service. Date of last examinations: Physical examination - 01/2020 Vision - 2019 Dental - 2019 Family History Review of Systems General health status: Patient states pain in back due to sitting at a desk for long periods, and patient states no fatigue, fever, sweats, weakness, weight issue or problem sleeping. Integumentary Skin: Patient states no change in skin color or texture, no bruising, itching, skin lesions, sores or mole. Patient does not wear sunscreen and does experience a lot of sun exposure. Hair: Patient states no changes in hair texture and no hair loss. Nails: Patient states no changes in nail color and texture, splitting, and cracking. HEENT Head: Patient states headaches occur during times when blood pressure is high, patients’ dienes any recent head trauma, injury, surgery, history of concussion, dizziness, and loss of consciousness. Neck: Patient denies any neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the neck. Eyes: Patient states poor vision from childhood and patient uses glasses. Patient denies any eye injury, itching, excessive tearing, discharge, pain, floaters, halos around lights, flashing lights, light sensitivity, and difficulty reading. Ears: Patient denies any hearing test, states no changes in hearing, pain, drainage, vertigo, ear infections other than during childhood and use of hearing aids. Nose, Nasopharynx, Sinuses: Patient states occasional snoring and denies any nasal discharge, frequent nosebleeds, nasal obstruction, postnasal drip, sneezing, allergies, use of recreational drugs, change in smell, sinus pain and sinus infections. Mouth/Oropharynx: Patient states no sore throats, mouth sores, bleeding gums, hoarseness, change voice quality, difficulty chewing or swallowing, change in taste, dentures, and bridges. Respiratory: Patient states no frequent colds, pain with breathing, cough, coughing up blood, shortness of breath, wheezing, night sweats or smoking. Cardiovascular: Patient states no chest pain, palpitations, shortness of breath, edema, coldness of extremities, color changes in hands, feet, hair loss on legs, leg pain with activity, paresthesia, sores that do not heal, and EKG and results. Breasts: Patients states no breast masses or lumps, pain, nipple discharge, swelling, changes in appearance, cystic breast disease, breast cancer, breast surgery, reduction, enlargement and does not perform BSE. Gastrointestinal: Patient states no change in appetite, heartburn, gastroesophageal reflux disease, pain, nausea, vomiting, vomiting blood, jaundice, change in bowel habits, diarrhea, constipation, flatus, last fecal occult blood test and colonoscopy results. Genitourinary: Patient states no pain on urination, burning, frequency, urgency, incontinence, hesitancy or changes in urine stream, flank pain, excessive urinary volume, decreased urinary volume, nocturia, and blood in urine. Female/male reproductive: Patient states no lesions, discharge, pain, mass, change in sex drive, infertility, STDs, or painful intercourse. Patient is involved in a sexual relationship with wife of 35 years, patient is heterosexual and had no other partner during lifetime, patient does not use any birth control and patient states no prostate or scrotal issues. Musculoskeletal: Patient denies any fractures, muscle pain, weakness, joint swelling, joint pain, stiffness, limitations in mobility, back pain, loss of height, and any bone density scan and results. Neurological: Patient denies any neurological deficits such as; pain, fainting, seizures, changes in cognition, memory, sensory deficits or problems with gait, balance, tremor or spasms. Psychosocial Profile Health practices and beliefs/self-care activities: Patient is physically active 1-2 hours a day and preforms activities such as light jogs around the neighborhood, treadmill in home gym or a game of soccer and does not perform any self-examination. Patient brushes teeth in the morning and before bed, does not floss and checks his blood pressure every night before bed. Nutritional patterns: Patient states appetite is regular, eats 3 meals and day and has snack often. Patient had oatmeal for breakfast, banana as a snack, salmon and rice for lunch, a bowl of fruit as snack, munges beans and fruit for dinner. Functional Ability: Patient is able to perform all activities of daily living independently such as dressing, bathing, eating, toileting, driving, shopping and cooking. Sleep/rest patterns: Patient gets 7-8 hours of sleep each night with no aids and states sleep is restful. Personal habits (tobacco, alcohol, caffeine, and drugs): Patient has stopped drinking caffeine 10 years ago and has no other personal habits such as tobacco, alcohol or drugs. Environmental history: Patient lives in two floor condo in an urban area. Family/social relationships: Patient has been married for 35 years, has 5 kids, 3 daughters and 2 boys and patient lives at home with wife and 2 youngest children. Cultural/religious influences: Patient states no cultural or religious influences on health. Mental Health: Patient states denies any anxiety, depression, irritability, stressful events, and personal coping strategies. Patient physical strength: Patient has a consistent appetite and is able to eat three meals a day with snack, the patients 24-hour meal recall shows the patient is eating notorious foods, with fruits, vegetables, dairy, grains, and protein. Patient Psychosocial/cognitive strength: The patient was able to recall vaccines taken from childhood and immunizations not taken before, the patient was able to recall illness such as chickenpox and has great memory with all his immunization and what vaccines he took on what date. Patient weakness: The patient seems to over work or not give body rest when in pain, as patient states back pain from sitting at a desk for long hours. The patient has high blood pressure and gets headaches so taking care of his body is very important.