Patient with Back Pain: Health Assessment

Biographical Data

Date: 27/01/18
Initials: M.P.
Age: 32
Date of birth: 13/04/1985
Birthplace: Tallahassee, FL
Gender: Male
Marital status: Married
Race: Asian
Religion: Baptist
Occupation: Construction worker
Health insurance: Yes
Source of information: The patient
Reliability of source of information: The information received is reliable

Present Health History/Illness

Reason for seeking care

Sharp back pain when lifting weights, weakness, and premature fatigue.

Health patterns

The patient has health insurance. He is a supporter of traditional medicine and does not take any stimulating drugs and folk remedies.

Health goals

To get qualified treatment in order to return to work as soon as possible.

Health Beliefs and Practices

Beliefs and practices

The patient has never resorted to healers’ help. Despite religious beliefs, he is a supporter of modern methods of treatment and does not believe in non-traditional rituals.

Factors influencing healthcare decisions

Healthcare decisions are made in accordance with the presented symptoms.

Related traits, habits or acts

The man does not smoke but periodically drinks alcohol in small doses. His work involves lifting weights and other procedures that require the use of physical strength.

Medications

Prescription medications

The patient did not consult the doctor concerning his problem.

Over-the-counter medications

Sometimes the man takes Oxycontin to reduce pain. To get rid of nasal congestion that periodically occurs, the patient takes Mucinex.

Herbals

The patient does not believe in the power of herbal preparations and does not trust non-traditional drugs in the form of ointments on a natural basis. According to Akilen, Pimlott, Tsiami, and Robinson (2014), the denial of methods of traditional medicine is increasingly manifested in the modern society.

Past History

Childhood diseases

Pertussis, chickenpox, pneumonia. Complications did not arise.

Immunizations

Appropriate vaccinations were made in childhood.

Allergies

The patient is allergic to bee venom.

Blood transfusions

None.

Major illnesses

None.

Injuries

Dislocation of the shoulder joint after an unsuccessful injury.

Hospitalizations

None.

Labor and deliveries

Regular employment.

Surgeries

Adjustment of the shoulder joint.

Use of alcohol

The patient sometimes drinks alcohol.

Use of tobacco

The man does not smoke.

Use of illicit drugs

None.

Emotional History

Mental, emotional or psychiatric problems

The patient feels depressed because of the lack of opportunity to work hard enough, which is caused by back pain.

Family History

Father

Patient’s father is a pensioner; he worked as a heating network operator for almost the whole life.

Mother

Patient’s mother died four years ago in a car crash.

Siblings

None.

Grandparents

None.

Psychosocial/Occupational History

Occupational history

The man works on construction sites.

Educational level

The patient finished school in 2003. He attended construction courses and received a specialty of a worker.

Financial background

The family of the patient is middle-class. Housing conditions are acceptable.

Roles and Relationships

Significant others

None.

Support systems

The respondent has a few male friends who support him. His relationships with his wife are also trusting.

Ethnicity and Culture

Ethnicity and culture

The patient is of Asian origin, but he is not familiar enough with the peculiarities of the Eastern culture.

Physical and social characteristics that influence healthcare decisions

The features of physical work partly affect the patient’s condition, tiring him.

Spirituality

Religious and spiritual needs

The man’s family are parishioners of the local Baptist church.

Self-Concept

View of self-worth

The respondent is well aware of the importance of his work; he is sufficiently purposeful and motivated.

Future plans

The man plans to receive the post of senior worker and wants to have a baby.

Review of Systems

Skin, hair, nails

The skin of the man has a natural color. His nails have no visible deformation marks. Hair is dark and does not fall out.

Head, neck, related lymphatics

There are no traces of injuries or other defects on the head and neck of the patient. Lymph nodes are not enlarged.

Eyes

The shape of eyes is typically Asian.

Ears, nose, mouth, and throat

Oral cavity and throat have no signs of infection. There are symptoms of decay in two teeth. Patient’s nose and ears are healthy.

Respiratory

Breathing is not intermittent; there is no shortness of breath.

Breasts and axillae

The symptoms of inflammation and neoplasm are not found.

Cardiovascular

Heartbeat is normal; no chronic diseases are identified.

Peripheral vascular

Blood flow is normal.

Abdomen

The respondent does not suffer from excessive weight, and there is not a large fat layer in the abdominal cavity.

Urinary

There are no problems with urination.

Reproductive

The patient has no children, but he confirms that his reproductive function is normal.

Musculoskeletal

No visible deviations are found.

Neurologic

Problems with the loin in accordance with the patient’s complaints.

Reference

Akilen, R., Pimlott, Z., Tsiami, A., & Robinson, N. (2014). The use of complementary and alternative medicine by individuals with features of metabolic syndrome. Journal of Integrative Medicine, 12(3), 171-174.

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