Health history interview - Essay Example

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His address is 10341-2062, New York and his phone number is 212.736.574. He is Caucasian and speaks the English language fluently. The patient, being the primary…
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HEALTH HISTORY INTERVIEW Kevin Smith Harrison is a twenty eight year old unmarried High School teacher born in Worcester, Massachusetts. His address is 10341-2062, New York and his phone number is 212.736.574. He is Caucasian and speaks the English language fluently. The patient, being the primary source of information, complained of severe coughing and sweating that kept him up at night.
Kevin said that the cough had blood stained sputum, which caused him a lot of discomfort. The patient also complained of fatigue and bouts of chills and sweats. He had clubbing of the third and fourth toes of his right foot, which appeared five days ago. The patient mentioned that he felt relief when he wears warm clothes and drinks warm water. The coughing was worst when he had to do heavy work or walk for a long distance. Kevin was disturbed by the fact that the drugs he had taken for the last one week had not caused substantial relief to his health.
Kevin had a severe case of measles at the age of three. He was hospitalized for three days. He received an immunization for pneumonia six months before coming to hospital. Kevin had been diagnosed with HIV a year before and he has been on a daily dose of ARVs. The patient was in the hospital for a CD4 count on 3 Jan 2012. He was on a high vitamin diet to boot his immunity (Reeders, 2001). The mother suffered from varicose veins at the age of sixty-five. There is no history of diabetes, heart problems or tuberculosis.
The skin of Kevin was moist, flexible and pink with some skin rashes near the elbow of the left arm. He bears a scar on the knee of the left leg from a fall he had when he was ten years old. The nails of the two toes on the right foot have clubbing. His hair is black and clean. It does not have scales or lice. The cornea is white and clear with no patches. The ears did not have any discharge or tenderness. The nose and sinuses do not have swellings or tenderness. The lips had cracks and there were small white wounds on the lower lip (Irwin, 2003). The lower and upper parts of the mouth were pink and it was not dry. The neck has tender lymph nodes and the lungs have fluid around them (Jamison, 2006). Kevin had a regular heart rate of 69/min. and his sexual health was normal.
Kevin was full of confidence and had high expectations that the tuberculosis would be cured. He stopped his morning jog and has not done it for two weeks because he says that it worsens the cough. He sleeps more often because he is more tired than normal. He also said that he felt better after a good rest. He was eating less because of the lack of appetite caused by the ARVs (Pribram, 2010). However, after being diagnosed with Tuberculosis, Kevin has increased his intake of zinc, vitamin A and D. Kevin is a Christian but went to church very rarely. He smokes half a packet of cigarettes and this can be the reason why the tuberculosis is severe.
The patient wanted assurance that the drugs given last week would cure the tuberculosis. He asked if there was any other medication that he would take that were more efficient. I advised him to stop smoking to allow the medication to work better and reduce the chances of the tuberculosis relapsing (Vassal, 2009). This can happen even after the treatment. I advised Kevin to eat well to avoid malnutrition, which is common with people who have tuberculosis.
Jamison, Dean. (2006). Disease control priorities in developing countries, Part 611. London:
The World Bank.
Frieden, Tom. (2004). Tomans tuberculosis: case detection, treatment, and monitoring. New
York: World Health Organization.
Pribram, Vivian. (2010). Nutrition and HIV. New Jersey: Wiley Production.
Vassal, Anna. (2009). The Costs and Cost-effectiveness of Tuberculosis Control. Amsterdam:
Amsterdam University Press.
Irwin, Alexander. (2003). Global AIDS: myths and facts : tools for fighting the AIDS pandemic.
New York: South End Press.
Reeders, Philip. (2001). Radiology of AIDS. New York: Springer.
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