History and Physical Assessment:
a. Biographical Data: A.G. is a 56 year old Hispanic male who is married with three children. All three children are young adults and living at home. He completed the sophomore year of high school, and works in the fields. Patient can communicate efficiently in English, but more articulate in Spanish. He is insured by Blue Cross. The patient’s primary diagnosis is ascending colon polyp. The operative procedure is DaVinci assisted Laparoscopic right colon resection possible ostomy. Patient was able to answer most of the questions. His wife translated whatever needed more explanation.
Client’s Current Health Status
b. Chief Complaint: Patient ...view middle of the document...
d. History of Present Illness: Recent colonoscopy on 4/20/11 identified 3 polyps. The polyps in the sigmoid colon and rectosigmoid junction were removed and pathology returned benign. The polyp located in the ascending colon was biopsied but not removed. It was tattooed with ink. Patient experienced no signs or symptoms with this diagnosis. Characteristics of diagnosis were that everything was fine, no disturbance in bowel movement. No other limitation or related symptoms associated with diagnosis. Treatment for diagnosis was surgery.
e. Past Health History: Patient is suffering from high cholesterol and hypertension. He is currently on Crestors 10 mg q Hs for cholesterol, and Benecar 140 mg/12.5 P.O. daily for hypertension. His last hospitalization was in 1992 for a broken left ankle. When he was 16 he had kidney stones removed. He has no known allergies. He took his blood pressure medication the morning of the surgery. He has never had a blood transfusion and he doesn’t smoke, do drugs, but does admit to drinking 12 packs of beer on the weekend and drinks coffee daily.
f. Family Health History: Patient did not give an account of his grandparents. He states that his father died of a brain hemorrhage, his mother had open heart surgery, has Chronic Obstructive Pulmonary Disease (COPD). His sister has diabetes, and his brother died of kidney failure.
g. Personal and Psychosocial: Patient is able to perform self-care activities, hold a full time job, has employer insurance, and owns a house which he shares with his wife and three children. Patient is a very active person at work. His developmental stage is Generativity vs. Stagnation. Patient has a physically demanding job that he enjoys, he is able to provide for his family which is very important to him. He is a successful and productive member of society. Patient routinely wears his seat belt, obtains routine exams, but admits that he has no exercise program, does not go to the gym, that his job is so physically active that he is tired when he comes home. Patient enjoys the relationship he has with his wife and children. He interacts with his mother and sister often. He stated that he was Catholic, but did not state whether he frequented Mass. He has a wonderful support system in his wife. He admits to sleeping well. He states that being proactive regarding his health is important to maintain a satisfying life. Patient admits to drinking a 12 pack of beer every week. He eats breakfast at Denny’s every morning: 2 eggs, meat, pancakes and coffee. He states he “eats everything”. He eats “Mexican food: chicken, beans, rice, tortillas”. Patient weighs 205 lbs., and is 5ft 5in, his BMI is 34.1 which indicates that he is obese. His food and fluid intake is above the recommended daily intake. His daily breakfast routine at Denny’s and alcohol use on the weekend has contributed to his increase BMI, despite his physical job. He indicated that he does not...