Health History
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...
Another way to put the patient at ease during moments like this is for the nurse to be absolutely certain that she is not showing any signs of being judgmental. If this happens, it could throw the patient off guard and create an uncomfortable situation where the patient no longer feels comfortable being honest with the nurse. Once this happens, the nurse will have an inaccurate patient history and
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