Subjective
Identification: A.L., a 32-year-old African woman who arrived by herself to the health center. The patient is indeed an honest chronicler.
“I’m only in for a health check – up,” CC said. I’m planning to start a new career, and the employer wants me to get checked out physically.
HPI: A.G. visited the hospital for his new company’s necessary physical exam. The most recent checkup had been in 2020, a year back. 3–4 times a month, she made complaints of having a headache. She did not need to seek medical assistance because the signs weren’t all that bad. Based on the intensity of the headaches, the candidate would take over-the-counter Tylenol 500mg either once or twice per day. There were no other spoken concerns.
PMH
List of health issues the client claimed to be anemic.
operations or hospital stays: Refuse prior surgery and hospitalizations
Vaccinations: The patient was given his first dose of the Covid 19 Pfizer vaccine last year 2021, as well as the flu vaccination in November or December 2021.
The patient suffers from seasoner allergy, that are particularly bad in springtime. He consumes 10 mg of cetirizine once or twice every day. Denies having food or medicine intolerance.
Prescription: The patient does not have a prescription for any drugs; however, she does use Cetirizine 10 mg for seasonal allergies and Tylenol 500 mg or Advil 200 mg for headaches. The patient admitted to taking collagen powder treatment for skin and said he occasionally consumes multivitamins.
Chemicals: The patient enjoys drinking 3–4 glasses of liquor twice weekly. Three times in a month, the patient smokes cigarettes with pals to spend quality time. In the morning, she has two cups of coffee. The patient disputes using illegal substances.
Family and social history:
A.L. is a pharmacist, and the highest degree she has earned is a doctorate degree. She is also currently single and living with her family. The patient is single and has no children. She feels safe and secure where he presently resides with his guardians and two siblings.
History of sexual activity and reproduction: The patient said she was last checked six years ago and has never had a STI before.
Social and spiritual support: The patient is at ease discussing issues with his allies and relatives.
Exercise and diet: The patient claims that he does not adhere to any diet. She eats primarily at home and occasionally consumes fast food five times per week. A.G. plays basketball or rides his bicycle for 30 to 40 minutes each day as his type of activity.
Safety: Patient is restrained whilst driving by a safety belt. Although he occasionally drives when texting, he refutes doing that while intoxicated. Patient claims she does not own a firearm and has never engaged in spousal abuse. Patient also has anemia, and don’t use any treatment.
Systems Analysis: Due to lack of exercise, the client has been experiencing fatigue recently. She added that her own anemia is a contributing factor. She claims that her sleeping habits have not changed, and he is not sick with a temperature, shivers, or night sweats. The patient disputes experiencing melancholy, anxiousness, or considering suicide. He took Tylenol for headaches that he reports having three to four times a month. He disputes any respiratory problems, wheezing, chest discomfort, breathing-related distress, or coughing. Along with N/V, stomach discomfort, bowel changes, indigestion, constipation, loose stool, farts, and bloating, the client also dismisses them. She doesn’t have painful urination, doesn’t wake up in the middle of the night to pee, doesn’t have any discharge, Urinary Tract Infection, or blood in urine, and that he can hold his fluid if necessary. She disputes any joint pain, muscle spasms, or pain in the muscles or joints. Whenever she works on autos, he does have back discomfort. The patient was fractured twice as a child. She suffered a left ankle broken bone while he was 14 due to a scooter incident that occurred, and he also suffered a left pinky toe fracture while playing football when he was 22. Both fractures were treated with a plaster and did not require any operation. The client never reported fainting, vertigo, drowsiness, specks in the eyes, tingling sensations, or loss of memory. They also didn’t notice they were becoming clumsier or losing their senses. Patient is not frequently unwell, bleeding, or bruised. Has no exceptional loss of weight or growth and has good heat and cold tolerance.
Risk evaluation
1. Smoking, aging, HTN, and family history all increase the risk of CVA (stroke) (CDC, 2021)
2. Potential for accidental or unintended fatality because of distracted driving (CDC, 2021).
3. Family history and diet are risk factors for T2DM (Hollier, 2021).
References
Centers for Disease Control and Prevention. (2021, March 2)
Reported STDs in the U.S. reach all-time high for the 6th consecutive year.
https://www.cdc.gov/transportationsafety/distracted_driving/index.html
Centers for Disease Control and Prevention. (2021, April 13)
Distracted Driving.
https://www.cdc.gov/std/default.htm
Hollier, A. (2021). Clinical guidelines in primary care (4th ed.).
Advanced Practice Education Associates Inc.
