Health history and screening of a young adult
Biographical data
Patient initials: l. p phone number: 1234567
Occupation: student employer: currently unemployed
Financial status: the patient is under complete care of his parents. Both the parents of the patient have adequate medical insurance. The patient however normally uses the health insurance of his mother for personal reasons.
Source and reliability of information: the source of the information is the patient himself. The patient is fully aware of his ongoing and very alert. There are no indications that the patient might have a lack of understanding of exactly what is going on. The information is thus very reliable and primary.
Past reports of serious or chronic illnesses: none
Past health screening: when the patient was nine years old he suffered a broken leg during a football game. The patient received adequate treatment and made a full recovery at a considerably quick pace. The patient does not suffer any pains currently as a result of the broken leg. There are also no deformities that resulted from the broken leg. The patient has made a full recovery and does not have any problems walking or running.
Past hospitalizations: the patient was hospitalized for twenty-four hours after breaking his leg. This was however only precautionary in order to ensure that no serious injury came to his leg.
Past operations: none
Family history
Alcoholism: the patient’s father is a chronic alcoholic who got addicted to alcohol at the tender age to twenty-four. He has been an alcoholic for thirty years.
Allergies: the patient’s mother has penicillin allergies. The patient also has a sister who has peanut allergies as well as penicillin allergies.
Arthritis: none
Asthma: the patient’s uncle on the father’s side is asthmatic. The asthma is chronic and the man gets asthma attacks on a regular basis. His asthma is especially difficult to contain and moderate doe to the severe nature of the attacks that he gets. The attacks also occur at an alarmingly high frequency.
Blood disorders: none
Cancer: none
Diabetes: the patient has a brother who is diabetic
Immunological disorder: none
Heart disease: the paternal grandfather of the patient died as a result of a heart attack. He did not have a history of heart problems and was very old when he got the heat attack that killed him. He was a hundred and three years old.
Kidney disease: none
Neurological disorder: none
Obesity: none
Obestric history: that information is unavailable currently.
Tuberculosis: the patient of the mother suffered from tuberculosis in her early thirties. She has however made a full recovery.
Nursing diagnosis: the patient might be at risk of developing asthma based on the fact that the patent has a paternal uncle who has chronic asthma.it is likely that the patient may develop asthma as a result of genetic coding through the family tree.
The patient is however very unlikely to develop heart problems and complications related to the cardiovascular system. This is because the family history of the patient does not reveal any tendencies to get heart attacks or other cardiovascular complications.
References
Brown, M. S. (2005). Health screening. New York: Wiley.
Medicaid, stronger efforts needed to ensure children's access to health screening services report to Congressional requesters. (2001). Washington, D.C.: The Office.
