Gordon's Functional Health Pattern (Teen) Adolescent Summary - Gordon's Functional Health Pattern

Biographical Data

Date of Visit: 8/31/2012, 10:30am.

Age

DOB: 3/2/1999

Race/Gender Hispanic, Female

Weight: 34 kg.

Height: 4ft. 7 inches

BMI: Normal Range 16.6 kg/m2

Phone [HIDDEN]

Reason for Visit: Evidence of exasperated asthmatic conditions. (Not an acute asthma attack). Became overexerted at school, 8/30/12. Restless night and complaints of tightness in chest and inability to catch breath. Slight wheezing can be heard during exhales. Potential asthma complications; albuterol has proven slightly ineffective in easing symptoms and discomfort.

Financial History: Patient is fully covered under parent's insurance. Mother works; serving as informant and escort to physician. Single parent household.

Past Health History: Patient is fully immunized and receives all routine health and wellness physicals and exams as appropriate. Last physical exam 5/30/2011, prior to beginning of summer camp. History includes struggle with exercise-induced asthma (albuterol use via bronchodilator). Describes an allergy to pineapple (reaction includes appearance of red, rash like spots on face). Mother provides multi-vitamin supplements. No reported childhood illness. No chronic illness.

Wellness Young Adult Behavior Assessment History Screening: In good, general health and physical condition. Mother indicates normal, full term pregnancy, although patient did have jaundice during first two weeks of life. Otherwise healthy infancy and early childhood. Patient is active in school activities (participates in physical education and cheerleading). Enjoys swimming and bike riding, helps with household chores. Lives in middle class community and walks/plays with two younger female siblings and peers within subdivision. No depression. Normal menstruation...

Last menstrual period began 8/17/12. Becomes winded in prolonged activities. Describes normal eliminations and voids. No history of hospitalizations, serious accidents or injuries.
Nutrition: Mother emphasizes healthy eating habits and fresh fruits and vegetables. Junk and processed food consumption is limited. Water consumed daily. 3-4 meals eaten per day with snacks allowed in between. No underage tobacco, drug or alcohol usage known or suspected.

Family History: Mother has Type 2 diabetes mellitus (T2DM), which she has been living with for 7 years. Father has hypertension and is overweight. Family history indicates susceptibility to T2DM with the disease occurring in both the maternal and paternal families. History of high blood pressure and depression on material side of family. Youngest sibling also has asthma. No other instances of asthma in family.

Review of Systems (as applicable)

General Health State: Facial expression and demeanor appropriate to situation. Speech is clear. Being monitored by mother. Withheld from school due to labored breathing. Self-medicating with albuterol and light pain medication as needed.

Skin: Mostly dry, warm. No excessive sweating.

Hair: Normal texture. No loss reported.

Nails: Normal color. No abnormalities reported.

Head: Aspirin taken at 9:10 AM for "slight head-ache." No dizziness reported.

Eyes: No change in vision reported. Patient wears eyeglasses.

Ears: Examination reveals no discharge, fluid or infection. Past history of infections in left ear -- typically in conjunction with cold/flu.

Nose/Sinuses: No change in sense of smell. Examination reveals no concerns.

Mouth/Throat: Recent tooth filling in back molar. No current toothache, alteration in taste or hoarseness. No throat irritation and normal coloring and appearance. Reports daily dental care.

Neck:…