Individual Client Health History and Examination

Individual Client Health History and Examination



Past Health Review

The patient is a diabetic Type 1 patient for the past 30 years. 4 years back angiography was done due to mild cardiac attack. Obesity is present in the family.

Physical Examination

Blood pressure of the patient was monitored along with the pulse rate; the patient has pressure over the chest. Chest x ray and Electrocardiogram was conducted that shows the abnormal pulse rate. The patient has acute pain on the left arm and shoulder. Blood tests to measure chemicals in the blood.

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Situation

Clients/ patient initial: K.TSex: MaleAge: 64

Occupation of Client/ patient: Retired General

Marital status: Married

May 2nd 2013

Health History/ Review of symptoms: Cardiac patient with Diabetes type 1

Complete assessment of health: K. T. has been a cardiac patient for the past 4 years and has been suffering from Diabetes Type 1 for past 30 years.

Background

History of Patient

Cardiac issues accompanied with obesity. High Blood pressure and Type 1 Diabetes

Assessment

The patient was carefully examined both during the pain and at normal condition. ECG was done to check the present condition of the heart after the initial mild stroke along with blood tests to measure the levels of different chemicals in the blood.

Recommendation

The patient has been recommended to take stress test to monitor the condition of the heart during physical activity and exercise. On the basis of the echocardiogram result the patient would need an angiography to determine clogged blood vessel, if any.

Health History and Examination

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3rd May 2013

Client/Patient Initials: K. T.

Sex: Male

Age: 64 years

Occupation of Client/Patient: Retired

Health History/Review of Systems

Neurological System: headache and tiredness after certain activities.

Head and Neck: No abnormalities

Eyes: Weak wears contact glasses.

Ears: no such abnormalities observed.

Nose, Mouth, and Throat: Normal, no previous signs of thyroid

Skin, Hair and Nails: Normal

Breasts and Aureoles: Normal

Lymphatic System: ...