Report on the Health History

Published: 2021-07-04 15:10:05
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Category: Health Care, Medicine

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The name of my patient is Boycel Verdejo. He lives at 8201 west bellfort avenue, Houston, Texas, 77071. He stated his phone number as (832)-477-7444, and his age is 38 years old, and his date of birth is 07/06/1980. Patient stated that he was born in Philippines but migrated to United State at the age of twelve years old. Mr Verdejo is a male, and is married with two young boys. His ethnic origin is from Bicolano, a Filipino ethnic group, and he works as a contractor for a construction company here in Houston, Texas. Mr Verdejo denies having any illness or disability, and stated that his primary language is English Language.
Perception of Health
Mr Verdejo’s perception about health is simply exercising regularly, and eating a balanced diet is the best way to stay healthy. He told me that he is participating in a marathon race at the end of this year. He believes when he engages in such activities, it put a smile on his face, and also put his body in shape.Past Medical History
Mr Verdejo denies having any childhood illnesses. However, he acknowledged that he had an accident through sky diving eight years ago, and resulted to a broken ankle. He was hospitalized at Memorial Hermann, Sugarland, and was referred to a bone specialist. He was hospitalized for a day, and the name of his physician is Doctor Jeremiah. He had a procedure for his right ankle, and the date he stated was 02/16/2010. The name of his surgeon was Doctor Christopher David, and the name of the hospital was Baylor College of Medicine. Mr Verdejo stated that he recovered fully through the help of a therapy. Furthermore, Mr Verdejo told me he had some vaccinations this year specifically 04/02/2018. Some of the vaccinations he had were measles, mumps, rubella, chickenpox, tetanus, hepatitis, and influenza. He had some dental done on June 18, 2018. Mr Verdejo denies having any allergies to medication or food. Mr Verdejo also denies taking any current medication.Review of Systems Mr Verdejo denies having any sign of weakness or fever. His skin is appropriate to race, and shows no sign of excessive dryness, or bruising, or lesion. He also shows no signs of lesion on the hair, and no recent hair loss was noted. Mr Verdejo denies having an unusual or severe headaches or any head injury. He denies having any issues with his eyes which may lead to difficulty with his vision or eye pain. I accessed Mr Verdejo’s ears, and see no sign of infections, or discharge from his ears.
Furthermore, his nose, and sinus are normal, and reflects no sign of discharge or sinus pain. Mr Verdejo has no sign of sore throat or mouth pain, and shows no signs of bleeding. Mr Verdejo’s neck shows no sign of lumps or swelling, and he stated not having any pains. Mr Verdejo shows no signs of wheezing or noisy breathing, and stated that he has no respiratory issues. In addition, Mr Verdejo denies having any cardiovascular disease that could lead to a chest pain, pressure, or palpitation. However, Mr Verdejo admitted on having some signs of numbness, and tingling occasionally due to his past surgery on his ankle.
Mr Verdejo denies having any difficulty in swallowing, and he said he has no issues related to abdominal pains. He has no issues with his urinary system that could lead to polyuria or oliguria. Mr Verdejo admitted that he is sexually active, and stated that he has no issues with sex activities and believes his sex is satisfactory with his partner. Mr Verdejo denies having any neurological problems, and shows no sign of stiffness or swelling around his joint. He shows no signs of bleeding around his skin, and said he has no history of diabetes or thyroid disease.
Development Considerations
Mr Verdejo grew up from a separated home. His mother left the house when he was six years old. He stated that growing up was hard without the love of a mother. However, his uncle was very supportive and he inspired him to never give up no his dreams no matter the circumstances.Cultural Considerations Mr Verdejo stated that holidays was always fun in Philippines. He admits to loving Christmas, and grew up participating in it with his friends, and love ones. Mr Verdejo admits that till today, he always embrace the spirit of Christmas season. In addition, he believes going home is very crucial since Christmas is a very special event in Philippine.
Psychosocial Considerations
The thought of Mr Verdejo’s mother leaving him at the age of six made him conclude that all women are the same. This keeps him from interacting with any girl while growing up. Mr Verdejo said his perception later changed when he travelled to United State. If I was to perform a physical assessment on him, I will focus on his ankle because he stated that he had some surgery due to an ankle fracture. Some teaching priority for Mr Verdejo will be interacting more with people in other to avoid past scenario. I will advise him to visit home often so he won’t have the feelings of been away for too long.
Collaborative Resources
Mr Verdejo has a very supportive wife and he said his kids are his motivation. His boss at work understands that Mr Verdejo is in college, and that gives him room, and time to focus on his studies with no burden from work or from his boss.Reflection I have learnt a lot here in Chamberlain College of Nursing but have a less experience on how to do a general health assessment on a patient. Working with Mr Verdejo gave me more knowledge, and understanding on how patient can respond or react to some questions. He was ready to answer all my questions, and made my assessment convenient. However, some barriers I encountered were that sometimes I ask him leading questions. Leading questions can make a patient give a non accurate respond.
In the future, I will ask him some open-ended questions that give me room to know him better. The only challenge we encountered was getting a quiet venue for the interview. Furthermore, I should have made some more enquiries about his mother, and ask if he has any plans of looking for her. In the future, I will approach my assessment by taking more elaborate note, and making sure I ask every detail information’s from the patient.

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