The purpose of this paper is to discuss the results of a health assessment on my patient. The health assessment included the health history. The history information was obtained by interviewing the patient, who was considered to be reliable. Other sources of data, such as medical records, were not available at the time of the interview.
Mr. Quines is a 32-year-old Filipino male, married. He is a registered nurse and currently employed in a long term care facility. He was born in the Philippines. He currently lives in the west part of the city.
Past Health History
When he was a child, Mr. Quines did not have any serious illness. However, he did had measles when he was 8 years old and chicken pox at the age of 10. Mr Quines has not had been in any major accidents or life threatening injuries. He just had sprained left ankle while playing basketball when he was 15 years old. He has been hospitalized once when he underwent hemorrhoidectomy last June 2018. He was diagnosed as hypertensive in the year 2012.
All of his childhood vaccinations were up to date. He gets vaccinated for influenza almost every year. His last tetanus shot was more than 10 years ago.
Mr. Quines sees his primary physician every year for a physical. His last physical exam was in October, 2017. He also sees his dentist annually for check-up and cleaning. His most recent dental check-up was in August, 2018. He never needed corrective lenses since he was a child, but he still have his visions checked annually. His last appointment was in November, 2017.
Mr. Quines has no known drug or food allergies. His current prescription medications include a 4 mg tablet of Mavic once daily to control his hypertension. Current over-the-counter medications include a daily vitamin C and occasional 200-500 mg of paracetamol or ibuprofen for fever and pains.
Mr. Quines is the third and youngest in the family. His father died due to electrocution at the age of 40. His mother is still alive and well and also have hypertension. His sister and brother are also still alive and both well. He mentioned that there is a positive history of cardiovascular disease in paternal and maternal side and breast cancer on maternal side. There are no other diseases in the family such as diabetes, blood disorders, mental illnesses, seizure disorder or kidney disease.
Review of Systems
Mr. Quines stated that he is generally healthy. He gained 2 kg of his weight when they had their vacation in the Philippines recently. He has mild eczema that occurs during extreme weather of hot and cold. Skin is light brown, warm and dry, and no rashes bruising or lesions. No hair loss, no unusually frequent or severe headaches; head is normocephalic. No history of glaucoma or cataracts, no eye pain or difficulty with visions; pupils are equally reactive to light. Ears are in normal alignment; no history of chronic infection or hearing loss, discharges or tinnitus. He denies any sinus pain, nasal obstruction or epistaxis. He usually has colds during cold or winter season. Mouth and throat does not have any lesions, no bleeding gums, sore throat, dysphagia or hoarseness. He wears braces since 2016. He brushes and flosses his teeth thrice a day. Neck is negative of any pain, swelling or tender nodes.
There are no history of lung disease, denies any chest pain or shortness of breath. He was a smoker before. He started smoking when he was 16 years old and consumes 3 sticks per day. He decided to quit smoking at the age of 25. Mr. Quines was diagnosed as hypertensive in the year 2012 and started taking prescribed medication. He has no chest pain, palpitation, or any dyspnea on exertion. He has no numbness or tingling or swelling in the legs; peripheral pulses are present bilaterally and capillary refills are less than 2 seconds. He reports good appetite with no recent change. He is sometimes constipated depending on the diet. Mr. Quines underwent hemmorhoidectomy last June 2018 and recovers well.. He has no history of urinary disease or problem. He performs testicular examination daily. He is married and lives with her wife; had no problem in erection and ejaculation. There are no history of arthritis or gout, no joint pain, stiffness or swelling. He has back pain that occurs occasionally which is work related. He submits himself to a chiropractor for evaluation and intervention. There are no neurological, hematological and endocrine problems or diseases.
Mr. Quines earned a degree of Bachelor of Science in Nursing in the Philippines. After graduating from the university, he started working as a nurse in the hospital and later on worked as a nursing instructor too. When he arrived here in Canada, he pursued his career as a nurse and fortunately he succeeded. He is currently working full time in a long term care facility located near their house. It is the main source of income of the family. And as the head of the family he stated that he is able to provide all the needs of the family.
He lives with her wife, two children and his sister. He was raised as a Christian, believes in God and attend to church regularly. Mr. Quines usually helps with house chores, likes gardening, and babysitting. He is independent in his activities of daily living. When he is off from work, he makes sure to have quality time with his family. They love to go to the parks or playground, swimming, watching movies, hosting get-togethers and karaoke. He has a routine of 1 hour running or jogging outdoors during summer, fall, and spring and on treadmill during winter season. Getting 8 hours of sleep at night is Mr. Quines’ normal pattern.
He states that he tries to eat healthy, avoiding salty and fatty foods and does not have any food intolerances. According to him, grocery and cooking are shared both for him and his wife. His typical diet includes white bread and coffee with cream for breakfast, white rice, stir fried vegetables and steamed fish for lunch and white rice, chicken soup or lean meat for dinner. He also takes 1 small cup of green tea before retiring. Mr. Quines drinks alcohol ocassionally and usually consume 2 bottles of beer. Most recent intake of alcohol was June 2018. He is currently a non-smoker and denies use of street drugs.
With regards to his interpersonal relationship, he said that he has a strong and healthy relationship with his family, his wife’s family, relatives and close friends. He also makes sure that he has at least 2 hours daily to spend time alone to reflect and meditate. They are adjusting really well with having their second baby. He considers his house, neighborhood and work environment safe. Mr. Quines states that his health goals are to control his high blood pressure, achieve and maintain ideal body mass index and maintain his optimum health.
Based on the results of health assessment data, Mr. Quines is fairly healthy person, who has not had any serious illness or life-threatening medical problems. He presents with high blood pressure that is currently under control with medication. He visits his physician and other health care professionals on a regular basis, exercise daily, eats healthy and takes medication as prescribed. Psychosocial status with family and friends is also healthy.