BIOGRAPHICAL DATA (10 pts)

Date:

18-11-2015

Initials:

DB

Age:

35

Date of birth:

20-04-1980

Birthplace:

Texas State

Gender:

Male

Marital status:

Married

Race:

Hispanic

Religion:

Muslim

Occupation:

Teacher

Health insurance:

TRS-ActiveCare

Source of information:

Internet and documented libraries

Reliability of source of information:

Very reliable sources

PRESENT HEALTH HISTORY/ILLNESS (15 pts)

Reason for seeking care:

He experiences insensitivity and burning sensation in the lower extremities that are swollen with a un-healing wound in the little toe. He has high blood sugar level that need to be monitored and controlled.

Health patterns:

DB has persistent pain in the right leg, and the blood sugar keeps on fluctuating between high to low.

Health goals:

He aims at improving his condition through proper medication and good health practices.

HEALTH BELIEFS AND PRACTICES (15 pts)

Beliefs and practices:

DB has been smoking for the past eight years. He observes his diet and strive to maintain a healthy diet by visiting a dietician once every month. DB believes in doing physical exercise every morning and performs blood sugar test thrice in a week.

Factors influencing healthcare decisions:

His healthcare decisions are influenced by financial factors and parental roles in the family. His condition has rendered his family poor due to over spending on the disease and his inability to perform errands as before. His fatherly role in the family compels him to make the best healthcare decisions so as to stay healthy to meet his family expectations.  

Related traits, habits or acts:

DB is an active smoker who can smoke about twenty-four sticks of cigarettes in a day. He has the habit of taking at least three meals per day and is a lover of sex.

MEDICATIONS (15 pts) (Please refer to your assignment guidelines.)

Over-the-counter medications:

Penicillin antibiotic taken as 500 mg orally every 6 to 8 hours for ten days.

Herbals:

None

PAST HISTORY (15 pts)

Childhood diseases:

No record of any chronic illness

Immunizations:

Was immunized against anthrax, polio, and DTaP. 

Allergies:

He experiences spring allergies shown by sneezing, running nose, sniffling, and stuffiness.

Blood transfusions:

He underwent blood transfusion once, two years ago, after a fatal accident.

Major illnesses:

The major illness is type II diabetes that has induced morbidities such as high blood sugar, insensitivity and pain in the lower extremities, heart coronary disease and skin infections.

Injuries:

He sustained minor head injuries during the road accident, was treated and discharged.

Hospitalizations:

In the last six months, he visited his physician eight times, was in the emergency department twice and got hospitalized for longer than a night twice. During hospitalization, he spent a total of fourteen nights in a level four hospital. He last had his eyes examined in September 2015 and, in the last six months, DB had his feet examined twice by a doctor.

Labor and deliveries:

N/A

Surgeries:

He had a minor surgery on the thigh as a corrective measure after the road accident.

Use of alcohol:

Does not use alcohol

Use of tobacco:

Has been an active smoker for the past eight years consuming at least twenty sticks of cigarette in a day.

Use of illicit drugs:

He does not use any illicit drugs.

EMOTIONAL HISTORY (15 pts)

Mental, emotional or psychiatric problems:

DB is always worried about his health and feels discouraged and afraid of his future health. His health is a regular cause of frustration to him, and he strives to improve his condition. However, he has neither mental nor psychiatric problems.

FAMILY HISTORY (15 pts)

Father:

DB's father was diagnosed with type II diabetes and died of heart failure

Mother:

Has no record of any chronic illness and still lives a healthy life.

Siblings:

Two of his brothers are experiencing diabetes-related complications and are on a medication program.

Grandparents:

Both grandparents were diagnosed with type II diabetes, and all of them died of diabetes-related complications.

PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts)

Occupational history:

DB was employed as a high school teacher in 1997 and has worked in three different high schools within the state of Texas. He is currently overwhelmed by his medical condition and has taken sick leave from work to meet his medication demands.

Educational level:

He is a degree holder from a local university in Texas having successfully completed a BSc Biochemistry course.

Financial background:

DB comes from a poor financial background. Having lost his father at age 10, the family assets left behind by the late father was insufficient to see him through his education. When he got a job, he became the breadwinner of the family but his medical condition has outsourced all his savings and resources through medical expenses sinking the family back to poverty.

ROLES AND RELATIONSHIPS (15 pts)

Significant others:

DB is married with two daughters and has a fatherly role in the family.

Support systems:

He meets his support needs from family, friends, his colleagues and, from the health care systems.

ETHNICITY AND CULTURE (10 pts)

Ethnicity and culture:

DB is of Hispanic origin who practices the Hispanic culture

Physical and social characteristics that influence healthcare decisions:

Hispanics are more focused on present needs than the future. This will influence DB to make decisions that are focused on the immediate satisfaction of his medical needs. Finally, the culture of the Hispanics to adjust to the environment other than controlling it will influence DB to be able to make healthcare decisions that help him adapt to his condition other than controlling his condition. The Hispanic culture promotes cooperative efforts in helping each other with respect for one another. This will be significant in influencing the community to offer support needs to DB.

SPIRITUALITY (5 pts)

Religious and spiritual needs:

DB professes Islamic faith and believes in one God and the spirit of Muslim brotherhood.

SELF-CONCEPT (5 pts)

View of self-worth:

DB has accepted the diagnosis of the disease, and with high self-esteem, he is optimistic that his condition will change for better in the future.

Future plans:

He plans to quit smoking and maintain a healthy lifestyle to help better his condition.

REVIEW OF SYSTEMS (20 pts) (Please refer to your assignment guidelines and chapter 4 of your text. This is NOT a physical assessment.)

Skin, hair, nails:

His finger and toe skin abnormally became thick, waxy, and tight. DB reports itchy and dry skin without moisture with some parts of the skin cracking. Besides, he complains of boils, infection of the hair follicles (folliculitis), sties, and infected nails.

Head, neck, related lymphatics:

The skin on the back of the neck is abnormally thick. No abnormality noted in other areas in this group.

Eyes:

He notes blurred vision, cataracts and glaucoma, thus, impaired optic system.

Ears, nose, mouth, and throat:

DB experiences a gradual loss of hearing ability with severe ear pain and otorrhea, and the mouth is abnormally dry. No abnormality noted in the nose and throat.

Respiratory:

He presents abnormality in breathing. He finds it difficult to breath and describes the situation as rapid and labored breathing. This means the respiratory system is not functioning well.

Breasts and axillae:

No notable abnormality in these areas.

Cardiovascular:

He notes chest pain and confirms coronary artery disease diagnosis. This posits that the circulatory system is not working well.

Peripheral vascular:

He notes intermittent claudication and describe the abnormalities as pain, cramping, or aching in the calves, thighs, or buttocks. This shows that the nervous system is not functioning properly.

Abdomen:

He notes upper abdominal pain due to Gastrointestinal Complications of Diabetes. This indicates that the digestive system is not functioning well.

Urinary:

DB present abnormal urination that occurs three times per hour and in large volumes. This indicates that the kidney is not functioning well.

Reproductive:

He notes lowered testicular mitochondrial function leading to premature ejaculations. This shows that the reproductive system is not functioning well

Musculoskeletal:

DB notes the inability to flex fully or extend his fingers. This shows that his Musculoskeletal system has been impaired.

Neurologic:

He notes insensitivity and burning sensation in the lower extremities. This shows that the nervous system is not working well.