Past Health History
Childhood Illness. Measles at age 3. No chickenpox, croup polio, ear infections, Kawasaki disease, or meningitis.
Surgical: no history of any curative medication
Medical history: 1992had a fracture on the left leg after a bicycle accident. The fracture healed after two months
1999 diagnosed with food poisoning after taking unknown food. Recovered after three day
Social History
No alcohol consumption at all.
Tobacco use. Smokes cigarettes occasionally
Medications; no prescription or any illicit drug abuse
Accidents or injuries; A bicycle accident at the age of eight,a healed fracture on the left leg.
Immunizations. Had a childhood immunization, last influenza three years ago. Had a T.B. skin test.
Last examinations. Last examination two months ago had a general check-up and described ‘normal”. Yearly prostate cancer screening
Current medications. Skin rashes cream, prescribed Antacids.
Family History.
D.N is the second child in the family, one brother, and two sisters; parents are married, father smokes cigar rates, mother drinks alcohol occasionally, not known disease or any health condition. Grandmother on father’s side K.W. aged 70, has diabetes; Grandfather on father’s side J.T. died at age 56 from cold blood murder. Grandmother on mother’s side C.M. aged 65 has cancer; Grandfather on mother’s side G.J. suffered from hypertension died at age 78. None of them divorced.
Review of Systems
General Health: the usual health reports “Fair”. No recent weaknesses, little fever and fatigue. Drastic weight loss from 180Lbs to 140Lbs. patient reports no stomach acid, some minor pain and little gases at night-time. Patient currently not on a diet. Involved in minor physical activities, active life.
Skin, Hair, and Nails. Had a minor history of skin infection. The patient reports a family history of slight allergies to meat, particularly when taken in great amount. No other additional allergies to drugs, plants or other animal products were stated. The slight change in skin color after the skin infection, no changes in the pigmentation, nevi, or mole. No bruises present. The patient reports a change in nail color and shape. The patient reports to chewing nails occasionally when frightened. Patient reports having been intoxicated once by toxic chemicals at age 10. Patient reports to caring for her hair, skin and maintains perfect hygiene and occasionally applying creams to retain the skin. The patient has no previous experience with herpes.
Head, Face, and Neck. Patient reports having no severe, or unilateral throbbing, sores appear on the mouth after consuming meat. The patient experienced headache once in a lifetime that occurred at ate 15. Patient reports of occasional pain on the neck and minor nausea when she gets anxious. Reports no history of migraines, patient reports no head damage or shock or any loss of consciousness, patient able to do her work perfectly with no sleep. Has no history of neck surgery except neck rashes.
Eyes: patient has no difficulty seeing or but has difficulty staring at objects that are far and small letters. The patient wears glasses while staring at distant objects. The patient reports blurry vision while staring at distant objects without glasses. The patient reports eye irritation that fades after a short time. Patient experiences pain in the eye after staring at distant objects for a long time. The patient reports no history of eye infections, damage, or surgery. The patient reports swollen eyelids after feasting on excess meat. The patient encouraged to exercise self-care actions as usual continually.
Ears: patient reports no hearing loss but experiences hearing difficulty after getting exposed to loud sounds. No earaches reported. No ear infections now or as a child, no O.M. history or any discharge. Patients had exposure to environmental noise from loud music. The patient clears ears with cotton buds weekly.
Nose: The patient reports no watery or runny nose during the allergic reactions to meat. The patient reports no allergies to dust or pollen. No colds. The patient reports no sinus pain or any nasal obstruction. The patient reports no decrease or change in the sense of smell
Mouth and Throat. The patient reports recent lesions and sores in the mouth after eating on meat. No reports of altered sense of taste. The patient refutes alcohol drinking but reports a history of occasionally smoking cigarettes from the age 21 to date. She has minor dental carries but no tooth loss. The patient brushes teeth twice a day and flosses once after two days. The patient does not wear bridges or headgears.
Neck: patient reports no pain, lumps, trauma, or injury but occasionally experiences rashes on the neck due to skin infections. Patient’s early treatment of skin rashes around the neck region. The patient reports yearly examination of the skin rashes that occasionally appear around the neck, creams have been continually applied to treat the rashes.
Thorax and Lungs: patient reports having unusual night cough always nonproductive. No blood present in the coughs, no odor in sputum, and clear phlegm. Cough normally gets relieved after taking water. The patient reports no family history of any lung disease, orthopnea, asthma. Minor chest pains after carrying out physical activity, no wheezing reported. The patient reports smoking starting at age 21 up to date. The patient admits living with a smoking father. Works in a supermarket with no exposure to chemical and environmental hazards.
Heart and Neck Vessels. The patient reports minor chest pains and tightness after physical activity but no cold sweats, nausea, or edema. The patient sleeps with a single pillow and has no history of anemia or hypertension.
Gastrointestinal: The patient reports a relatively good appetite with minor changes. No reports of dysphagia. The patient reports heartburn after eating food rich in carbohydrates. Occasionally swallows antacids minutes before eating food rich in carbohydrates to relieve discomfort, no reports of abdominal pain, vomiting, or nausea. The patient reports a history of food poisoning at the age of 20. No history of liver or gallbladder disease reported. No history of diarrhea uses of purges or constipation reported
Peripheral Vascular: patient reports some burning pain of the left leg when running or moving upstairs and heavy objects. The pain is reported to appear abrupt and worsens when sited for a long period. The patient admits to having tried several methods of relieving pain. Active lifestyle: The patient denies a history of vascular problems. The patient currently smokes but denies skin changes on other parts of the body except for the neck. Legs are equivalent in length. No reports of lymph nodes enlargement. The patient works in a supermarket and stands for more than 7 hours a day.
Male Genitourinary:
No reports of any sexually transmitted disease. No urinary symptoms like dysuria or urethral discharge. No pains in the flank, groin. The urine color is yellow and no history of any kidney disease. No history of problems in the genital area, lesions, or sores. States sexual satisfaction and relationship as ‘satisfied.’ Married for 20 years now and enjoys sexual activities, feels satisfied, and communicates perfectly with the partner.
Musculoskeletal: The patient admits to minor joint pains after physical activity but no reports of stiffness, heat, redness, or atrophy. No reports of Rheumatoid Arthritis. Reports a history of fractures on the left leg, bone pain, accidents that affected the joints on the left leg. Reports no back pain or lower back pain. No history of arthritis, the patient does minor physical activity. The patient reports no limits when bending, cleaning the house, no disturbances with self-confidence.
Neurologic: The patient reports no past of seizure complaints, fainting, or stroke. Reports of no alcohol use or use of street drugs. Reports of occasional weakness but no history of tremor, paralysis, or coordination problems.
Anus and Rectum: The patient reports no discomfort, no anal fissures, or lesions. The rectal wall is well intact, and no tenderness reported