Comprehensive Health Case Study
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Current [Comprehensive Health History Name of interviewer:_____________________________ Date of assignment: _______________
Identifying data | Y | N | Name of interviewer | X | | Name of patient | X | | Date and time of interview | X | | Location of interview | X | | Source of data | X | | Reliabilty of informant | X | | Ethnicity/culture | X | | Age and gender | X | | Date/place of birth | X | | | | | Chief complaint | Y | N | Chief complaint | X | | | | | Present Illness | Y | N | Onset of symptoms | X | | Timing | X | | Character, quality, quantity, location | X | | Associated events | X | | What lessens symptoms | X | | What increases symptoms | X | | Treatments …show more content…
Brown voiced receiving Hepatitis B vaccination and Influenza vaccination at his dialysis clinic; he also recalls getting tetanus shots years ago for dog bite.
Social History: Mr. Brown migrate from Mexico to the United States 40 years ago, he works at a local hardware store five days per week, and enjoys hanging out with his buddies having a drink, barbecuing or playing cards. Mr. Brown has 4 grown children three boys and one girl, he was married but after “12 years into the marriage it fell apart”, he is now divorced and single and with no significant relationships. He is not associated with any religion but remember growing up attending a Catholic church.
Behavioral History: Mr. Brown states he was a chronic alcohol drinker however when he became very sick with his diagnosis of diabetes, kidney disease and hypertension he stopped drinking; now he consumes a beer when he hangs out with his buddies once per week. He smoked a pack of cigarette for 45 years now he does not smoke. He is on Medicaid to meet his medical needs; he has never gone to see a doctor until his wife encouraged him when he began to feel ill as a result of his diabetes. At present he is a regular dialysis patient at a local clinic and sees his nephrologist whenever he has a concern or regularly on his dialysis days. Mr. Brown eats at least twice per day a renal diabetic diet, he does not exercise but walk short distances to run errands. He states he is not a drug user or addict; he …show more content…
Previous problems: no previous problems, no reported rectal bleed, hemorrhoid, sore, or pain.
Neurological review of system:
Current problems: report generalized weakness, low moods.
Previous Problems: admits to no previous neurological problems, no memory impairment, headache dizziness, vertigo, fainting spells, paralysis, seizures, numbness, tingling, tremors or involuntary movements.
Musculoskeletal review of system:
Current problems: report swelling to ankles, generalized weakness, no pain.
Previous problems: muscle and joint pains (gout) to knees in the past relieved by Tylenol and Prednisone no stiffness, backache, redness, swelling or trauma to joints or muscles, cramping occasionally on dialysis increase fluid removal.
Psychiatric review system:
Current problems: report low mood and feeling of depression as a result of present onset of systems.
Previous problems: no nervousness, tension, memory changes or suicidal ideation occasionally anxious unknown reason presently on Xanax prn.
Endocrine review of systems:
Current problems: no current thyroid
Current [Comprehensive Health History Name of interviewer:_____________________________ Date of assignment: _______________
Identifying data | Y | N | Name of interviewer | X | | Name of patient | X | | Date and time of interview | X | | Location of interview | X | | Source of data | X | | Reliabilty of informant | X | | Ethnicity/culture | X | | Age and gender | X | | Date/place of birth | X | | | | | Chief complaint | Y | N | Chief complaint | X | | | | | Present Illness | Y | N | Onset of symptoms | X | | Timing | X | | Character, quality, quantity, location | X | | Associated events | X | | What lessens symptoms | X | | What increases symptoms | X | | Treatments …show more content…
Brown voiced receiving Hepatitis B vaccination and Influenza vaccination at his dialysis clinic; he also recalls getting tetanus shots years ago for dog bite.
Social History: Mr. Brown migrate from Mexico to the United States 40 years ago, he works at a local hardware store five days per week, and enjoys hanging out with his buddies having a drink, barbecuing or playing cards. Mr. Brown has 4 grown children three boys and one girl, he was married but after “12 years into the marriage it fell apart”, he is now divorced and single and with no significant relationships. He is not associated with any religion but remember growing up attending a Catholic church.
Behavioral History: Mr. Brown states he was a chronic alcohol drinker however when he became very sick with his diagnosis of diabetes, kidney disease and hypertension he stopped drinking; now he consumes a beer when he hangs out with his buddies once per week. He smoked a pack of cigarette for 45 years now he does not smoke. He is on Medicaid to meet his medical needs; he has never gone to see a doctor until his wife encouraged him when he began to feel ill as a result of his diabetes. At present he is a regular dialysis patient at a local clinic and sees his nephrologist whenever he has a concern or regularly on his dialysis days. Mr. Brown eats at least twice per day a renal diabetic diet, he does not exercise but walk short distances to run errands. He states he is not a drug user or addict; he …show more content…
Previous problems: no previous problems, no reported rectal bleed, hemorrhoid, sore, or pain.
Neurological review of system:
Current problems: report generalized weakness, low moods.
Previous Problems: admits to no previous neurological problems, no memory impairment, headache dizziness, vertigo, fainting spells, paralysis, seizures, numbness, tingling, tremors or involuntary movements.
Musculoskeletal review of system:
Current problems: report swelling to ankles, generalized weakness, no pain.
Previous problems: muscle and joint pains (gout) to knees in the past relieved by Tylenol and Prednisone no stiffness, backache, redness, swelling or trauma to joints or muscles, cramping occasionally on dialysis increase fluid removal.
Psychiatric review system:
Current problems: report low mood and feeling of depression as a result of present onset of systems.
Previous problems: no nervousness, tension, memory changes or suicidal ideation occasionally anxious unknown reason presently on Xanax prn.
Endocrine review of systems:
Current problems: no current thyroid