Health screening and history of an Adolescent or young Adult Client



Health screening and history of an Adolescent or young Adult Client

Biographical Data

Patient/Client Initials: D.M

Phone No:

Address: Phoenix, AZ

Birth 07-30-1996

Age: 16

Sex: Female

Birthplace: Phoenix, AZ

Marital Status: Single

Race/Ethnic Origin: African American

Occupation: Student from high school

Employer: Departmental Store (Wal-Mart)

Financial Status:

Patient receives health insurance from her parents. She is dependent, is covered under the health insurance of her father, and is supported by her family. She belongs to an upper middle class with adequate income for a moderate lifestyle, including good coverage of all health concerns.

Source and Reliability of Informant:

Source of the information is from the patient, in the presence of her mother. The information is very reliable. Patient, while providing information, is alert and well oriented with time, place, and person.

Past Use of Health Care System and Health Seeking Behaviors:

Patient is a diagnosed case of sickle cell anemia

Present Health or History of Present Illness:

My patient is 16 years old, African American female young adult with a known history of sickle cell anemia, diagnosed at the age of five years. Patient presented to the emergency department with a 2-day h/o bilateral knee pain. The pain initiated on Friday morning at about 10:00 am during the morning shift of the patient, at the departmental store. According to the patient, the pain was aching in nature, and onset was described to be gradual. The patient was unable to sleep on Friday night due to the increasing severity of pain, which gradually progressed in severity reaching to 8/10 today. She further explained that pain exacerbated while walking or standing for long. The pain did not have any significant relief with Percocet, which patient was prescribed. This episode of knee pain was distinct from any prior episodes of pain crisis. She also complains of chills, and mil shortness of breath (SOB). No other associated complain, such as fever, chest pain, cough, or abdominal pain. No recent h/o trauma to the knees.

Past Health History

General Health:

Overall health is satisfactory, according to the patient. No episode of serious complications. On and off history of minor joint pains, effectively relieved by Percocet. Patient describes doing low impact exercises on a regular basis.

Allergies:

No known drug or food allergies.

Reaction:

No h/o reaction from transfusion or any administered drug.

Current Medications:

5 mg Folic Acid QD

1 Tablet of Percocet (5/325mg) at 4 - 6hr PRN for pain

Last Exam

3-weeks prior

Immunizations:

Complete according to EPI

Childhood Illnesses:

Known case of sickle cell anemia

Serious or Chronic Illnesses:

Known case of sickle cell disease (milder form)

Past Health Screening:

None

Past Accidents or Injuries:

At the age of nine years, patient experienced a fall and suffered from a second-degree right radial fracture. No deformity was noted at present.

Past Hospitalizations:

History of 3-4 episodes of hospitalizations with the complaint of pain. Discharged from ED with appropriate treatment. No h/o serious complication of the disease, resulting in hospitalization.

Past Operations:

None

Family History

(Specify which family member is affected.)

Alcoholism (ETOH use/abuse): None

Allergies: Father suffers from seasonal ...