|Date of birth:||13/04/1985|
|Source of information:||The patient|
|Reliability of source of information:||The information received is reliable|
Present Health History/Illness
Reason for seeking care
Sharp back pain when lifting weights, weakness, and premature fatigue.
The patient has health insurance. He is a supporter of traditional medicine and does not take any stimulating drugs and folk remedies.
To get qualified treatment in order to return to work as soon as possible.
Health Beliefs and Practices
Beliefs and practices
The patient has never resorted to healers’ help. Despite religious beliefs, he is a supporter of modern methods of treatment and does not believe in non-traditional rituals.
Factors influencing healthcare decisions
Healthcare decisions are made in accordance with the presented symptoms.
Related traits, habits or acts
The man does not smoke but periodically drinks alcohol in small doses. His work involves lifting weights and other procedures that require the use of physical strength.
The patient did not consult the doctor concerning his problem.
Sometimes the man takes Oxycontin to reduce pain. To get rid of nasal congestion that periodically occurs, the patient takes Mucinex.
The patient does not believe in the power of herbal preparations and does not trust non-traditional drugs in the form of ointments on a natural basis. According to Akilen, Pimlott, Tsiami, and Robinson (2014), the denial of methods of traditional medicine is increasingly manifested in the modern society.
Pertussis, chickenpox, pneumonia. Complications did not arise.
Appropriate vaccinations were made in childhood.
The patient is allergic to bee venom.
Dislocation of the shoulder joint after an unsuccessful injury.
Labor and deliveries
Adjustment of the shoulder joint.
Use of alcohol
The patient sometimes drinks alcohol.
Use of tobacco
The man does not smoke.
Use of illicit drugs
Mental, emotional or psychiatric problems
The patient feels depressed because of the lack of opportunity to work hard enough, which is caused by back pain.
Patient’s father is a pensioner; he worked as a heating network operator for almost the whole life.
Patient’s mother died four years ago in a car crash.
The man works on construction sites.
The patient finished school in 2003. He attended construction courses and received a specialty of a worker.
The family of the patient is middle-class. Housing conditions are acceptable.
Roles and Relationships
The respondent has a few male friends who support him. His relationships with his wife are also trusting.
Ethnicity and Culture
Ethnicity and culture
The patient is of Asian origin, but he is not familiar enough with the peculiarities of the Eastern culture.
Physical and social characteristics that influence healthcare decisions
The features of physical work partly affect the patient’s condition, tiring him.
Religious and spiritual needs
The man’s family are parishioners of the local Baptist church.
View of self-worth
The respondent is well aware of the importance of his work; he is sufficiently purposeful and motivated.
The man plans to receive the post of senior worker and wants to have a baby.
Review of Systems
Skin, hair, nails
The skin of the man has a natural color. His nails have no visible deformation marks. Hair is dark and does not fall out.
Head, neck, related lymphatics
There are no traces of injuries or other defects on the head and neck of the patient. Lymph nodes are not enlarged.
The shape of eyes is typically Asian.
Ears, nose, mouth, and throat
Oral cavity and throat have no signs of infection. There are symptoms of decay in two teeth. Patient’s nose and ears are healthy.
Breathing is not intermittent; there is no shortness of breath.
Breasts and axillae
The symptoms of inflammation and neoplasm are not found.
Heartbeat is normal; no chronic diseases are identified.
Blood flow is normal.
The respondent does not suffer from excessive weight, and there is not a large fat layer in the abdominal cavity.
There are no problems with urination.
The patient has no children, but he confirms that his reproductive function is normal.
No visible deviations are found.
Problems with the loin in accordance with the patient’s complaints.
Akilen, R., Pimlott, Z., Tsiami, A., & Robinson, N. (2014). The use of complementary and alternative medicine by individuals with features of metabolic syndrome. Journal of Integrative Medicine, 12(3), 171-174.