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This health history involves the health needs and characteristics of a 23-year-old Caucasian male. Reason for Care
The reason this patient is seeking care is multi-fold. He bears all the signs of an intravenous drug user and has an infection in his arm, clearly from injecting substances into his body with unclean needles or in unsanitary manners. The patient demonstrates an extreme shortness of breath, dry mouth, constricted pupils and seems disoriented, in conjunction with moments where he appears drowsy. When he walks, he has an extremely slouched appearance, as if his arms and legs are very heavy. His nose is frequently running and when asked about his weight loss, he provides unclear, unspecific answers. All the patient can attest to is the fact that he's lost 20 pounds in the last five months.
The reasons that patient is seeking care are articulated by him as follows: he wants a prescription for painkillers. He's requesting opiate-based painkillers like oxycodone. He wants the infection in his arm treated. He also mentioned that he's found blood in his urine and that he wants to be "checked out for that."
Demographics subjective data and subjective data
The patient is white, Caucasian, and 23 years old. It is his first time receiving any formal health care in five years. He is 6-foot one, and 150 pounds. He has no allergies and no pre-existing conditions, nor any adverse health histories in his family. The patient's vital signs are sluggish: he has a respiratory rate of 9 and a temperature of 102 F. His blood pressure is 90/60. He is unemployed and has no address which he can offer. He says his parents live in a nearby affluent suburb, but he does not stay with them. Aside from his extreme paleness and weight loss, he looks healthy, at least from far away. However, upon closer examination he has signs of truly ill health. He suffers from chills and appears to be sweating. When listening to his heartbeat he appears to suffer from a heart murmur. His fingers has small, red/purplish bumps on his fingers and toes which he says hurt to touch. Other troublesome signs are small dark spots on the palms of his hands; he also has those spots on his fingers and toes as well. Other areas of his skin bear the signs of broken blood vessels. He has tiny spots on his fingernails and on his chest, and even in the whites of his eyes that demonstrate the signs of broken blood vessels. His legs are swollen.
He denies being sick; and denies a pre-existing condition. He also denies using drugs of any sort. He finished high school and has completed some college.
The client explains that his parents are still married, but that they sleep in separate bedrooms and they have for years. His father is the CEO of a company; his mother is a designer who works out of the house. He has a younger sister who he seldom sees. She is eight-years old. He's not allowed to see his sister, he says, because he was kicked out of the house. He won't explain why he was kicked out. He just explains that his parents won't let him stay there. He says that he doesn't want to stay there anyway, explaining that it is an unhappy household and that his parents either scream at one another or ignore each other in tense silence. The patient won't explain where he sleeps or where he receives his mail, explaining only that "he knows people" and that he "finds a place."
The patient left college because his parents refused to continue to pay his tuition bills. The patient won't explain why that occurred. He claims to have been studying architecture in college and to have enjoyed it. The patient claims that he has a lot of friends and that for fun, he goes to parties and concerts. He does not have a girlfriend, he claims, because "they're too expensive." He has a girlfriend in high school, he explains, but she moved away and then "she died." The patient won't explain what the girlfriend died of, but appears to be crying as he thinks of her. He has no plans to return to college. He currently looking for a job, but intending to work in a bookstore or in a video shop, someplace which is quiet, he explains.
The patient's current health is extremely poor. Aside…[continue]
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