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Cultural Assesment of a Patient

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Submitted By maxmoxon
Words 508
Pages 3
History and Physical
Nalini Sharma
College of Staten Island: NRS 702 March 12, 2016

Source of history: Client provided information: articulate and coherent.
Chief Complaint (CC): Client says, “I have fever, cough and sore throat with itching and running nose.’’
History of present illness (HPI): 23 year old male reports that since last 2-3 days he has fever, cough with pain in throat which is itching and running nose. Patient also says that he feels pain all over the body due to present illness.
Past medical history (PMH): Patient denies any past medical history. Patient states that he is healthy young man.
Medications (Meds): No current medication except Tylenol for fever yesterday.
Allergies: No known allergies
Family history (FH): Both parents alive and in good health. Mother has diabetes type 2 and father has hypertension.
Social History (S Hx):
Marriage status: never married
Living conditions: living in a bedroom apartment with parents and brother.
Occupation: part time job in law office and going to Law College.
Smoking/alcohol/drug abuse: Admits to drinking occasionally, denies smoking and illicit drug use.
ADLs: Reports active and walking to college, doing exercise on regular basis. Client reports eating vegetarian meal, no increase or decrease in appetite.
Religion and cultural history: Orthodox Jewish.
Sexual activity: reports only with girl friend who he has been with for 2 years.
Review of Systems (ROS):
General: Patient reports in good health with appropriate height and weight according to age. Client reports sick and weak due to illness.
Skin: Reports no changes in skin color or texture.
HEENT: Client c/o occasional headache only if he does not take rest.
Eyes: Client wears glasses and this time reports watery eyes. Denies any photophobia and diplopia problem.
Ears: Reports hearing intact denies any discharge, pain and tinnitus.
Nose: Client c/o running nose and also c/o some nasal congestion.
Throat: Client c/o sore throat.
Neck: Client c/o mild pain in neck since illness. Client denies abnormal swelling and nuchal rigidity.
Breast: Client denies any discomfort in breasts, nipple discharge and change in size.
Respiratory: Denies problem with breathing and shortness of breath but client c/o cough occasionally. Also denies purulent sputum, hemoptysis.
Cardiovascular: Denies palpitation and chest pain.
Gastrointestinal: Client denies any vomiting, diarrhea, constipation abdominal discomfort. Client reports healthy eating habits.
Peripheral vascular: Denies c/o weakness, numbness, swelling and pain in any extremity.
Urinary: Client denies painful urination, frequent urination any color changes or odor.
Genital: Client denies any rash, lesions, vesicles or itching on genital area.
Musculoskeletal: Client denies any back, pain, legs pain and any problem with posture.
Psychiatric: Client denies depression, anxiety and any suicidal ideation.
Neurological: Client c/o headache occasionally but denies any other neurological problem like: confusion, headache, dizziness, numbness, tingling and weakness in legs or arms.
Hematological: Client denies any bleeding problem.
Endocrine: Client denies polyuria, any hair loss, temperature intolerance and constipation

Reference
Bickley,L,& Szilagyi,P(2013). Bates’ Guide to physical examination and history taking- (11th ed.,pp.962-963).

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