Health History Of A 45 Year Old Male With Type 2 Diabetes

Stuck on Your Essay? Unlock Instant academic writing Help!

Submit a "do my essay" request and proceed to do whatever your heart desires.

Get Writing Help Now!

Health History of a 45-year-old Male with Type 2 Diabetes Mellitus

Introduction

Health history assessment is an integral component of patient care that provides healthcare professionals with essential information to be cognizant of a patient’s past and present health status. The comprehensive tool helps identify health problems, abnormal findings, and issues and documents the patient’s response to various health conditions. A good health history is the foundation for a successful care plan based on the patient’s needs. This case presentation portrays Mr. J.R., a 45-year-old male patient who has type 2 diabetes mellitus and consented to this interview for educational purposes.

Biographic Data

Mr. J.R. is a 45-year-old African American male, born on April 15, 1980, in Chicago, Illinois. His address is 234 Oakwood Avenue, Apartment 5B, Chicago, Illinois, and he can be reached at (312) 555-7890. Mr. J.R. has been married for 15 years and lives with his wife and two children. Mr. J.R. is Christian and goes to church services regularly. Mr J.R. possesses a bachelor of science in business administration. He has served as a ten-year veteran financial analyst at the neighbourhood bank, which affords him fixed income and coverage under a health insurance program.

Source and Reliability

The information for this health history was obtained directly from Mr. J.R. during a 90-minute interview session. He was alert, oriented, and cooperative during the assessment process. Mr. J.R. provided detailed responses to questions and recalled past medical events, dates, and treatments well. Mr. J.R.’s responses were supported by the medical reports he voluntarily produced, making him a plausible source of information.

Reason for Seeking Care

Mr J.R. stated, “I have been more fatigued than usual over the past month, and I have noticed my blood sugars have been higher than usual even though I have been following my diet and medication regimen.” He does admit to testing his blood glucose twice daily as ordered by his physician, with results of 160-180 mg/dL in the morning and 140-160 mg/dL in the evening, which is higher than his goal range of 80-130 mg/dL. Sharma et al. (2022) report that chronic hyperglycemia can lead to fatigue and can indicate that a change in diabetes control needs to be initiated. Mr. J.R. is concerned about these symptoms because they affect his work performance and quality of life.

Present Health or History of Present Illness

Mr J.R. was diagnosed with type 2 diabetes mellitus seven years ago and has had, in general, good blood sugar control with oral medication and lifestyle modification until recently. According to Crasto et al. (2021), symptoms of diabetes should be monitored regularly to prevent complications. Mr. J.R. has had increased fatigue, polyuria, and mild polydipsia for nearly four weeks. He has no fever, weight gain or loss, vision changes, numbness or paresthesias of extremities, or nonhealing wounds. His recent quarterly HbA1c was done three months ago and was 7.2%, within his target range as prescribed by his endocrinologist. He has been taking Metformin 1000mg twice daily and Glipizide 10mg once daily as directed, without missing any doses. Mr J.R. reports feeling more stressed at work since he has a two-week critical deadline.

Past Health

Mr. J.R.’s history of previous diagnoses includes type 2 diabetes mellitus in 2018, hypertension in 2016, and hypercholesterolemia in 2017. Schiborn and Schulze (2022) state that early identification and treatment of comorbidities in diabetic patients significantly reduce the risk of complications. Mr J.R. admits to allergies to penicillin with a resulting rash and facial swelling and sulfa medications with resultant intense itching. He denies environmental or food allergies. His medication includes Metformin 1000mg twice daily, Glipizide 10mg once daily, Lisinopril 10mg daily, and Atorvastatin 20mg daily. He also uses Ibuprofen 400mg for headaches and a daily multivitamin. Mr J.R.’s immunization status is current, with his last influenza vaccination in October 2024, COVID-19 booster in September 2024, Tdap in 2023, and pneumococcal vaccination in 2022. His tuberculin skin test in 2023 was negative. In terms of hospitalization, Mr. J.R. was hospitalized once in 2018 for diabetic ketoacidosis when diabetes was diagnosed, and he had an appendectomy in 1995 without any complications. He denies any issues with anaesthesia. Mr. J.R.’s social history is significant for quitting smoking 10 years ago after a 15-pack-year history of smoking one pack a day. He does use alcohol on occasion (1-2 beers a month) and denies any recreational drug use. He does a 30-minute walk for exercise three times weekly.

Family History

The family history of Mr. J.R. is significant regarding diabetes and heart disease. According to Cai et al. (2021), heredity plays a vital role in determining the risk for type 2 diabetes in an individual. His father died at the age of 68 years from myocardial infarction and had type 2 diabetes and hypertension. His mother, 70 years old, has hypertension and osteoarthritis. Mr. J.R. has two siblings: a 48-year-old brother with type 2 diabetes and a healthy 42-year-old sister. His paternal grandfather passed away at the age of 72 years from a stroke, and his father’s grandmother passed away at the age of 76 years from breast cancer. His mother’s grandparents both lived into their 80s, with his maternal grandfather having type 2 diabetes. Mr. J.R. has two children, aged 13 and 15, who are healthy and have no chronic diseases. No family history of kidney disease, seizure disorder, drug or alcohol addiction, or mental illness.

Review of Systems

Mr. J.R.’s general health has been good until lately, when he complained of fatigue. He has a weight of 195 pounds and a height of 5’10” (BMI 28). As Jarvis (2023) states, a review of systems shows mild symptoms that the patient may not actually report as presenting complaints. Mr J.R.’s skin has no rashes, lesions, or pigmentation changes. He denies abnormalities in growth or brittleness of nails and hair. His head is normocephalic with no headache or history of head trauma. His vision is 20/30 in both eyes with correction, and he had an eye exam six months ago. His hearing is normal bilaterally, with no tinnitus or vertigo. Mr J.R. has occasional nasal congestion when allergy season arrives but denies epistaxis or sinusitis. His mouth and throat are free of lesions with intact dentition; his last dental exam was four months ago. His neck is supple without lymphadenopathy, mass, or thyroid gland enlargement. Mr. J.R. denies axillary swelling or tenderness along with breast mass or discharge. His respiratory exam has clear breath sounds with no cough, wheezing, or shortness of breath.

Cardiovascular examination shows regular rate and rhythm, with no chest murmurs, palpitations, or pain. Peripheral pulses are equal and strong bilaterally, with no varicosities or oedema. Gastrointestinal examination shows normal bowel function with no constipation, diarrhoea, or stomach pain. Mr. J.R. reports daily urinary habits, except for frequency during the past month, which he attributes to his elevated blood glucose levels. He denies incontinence, hematuria, or dysuria. Genitourinary examination is negative for testicular pain, mass, or impotence. He is sexually active with his wife and has no sexual health problems. The musculoskeletal examination is negative for normal range of motion of all joints without arthritis, muscle weakness, or pain in the back. Neurological examination is negative for seizures, syncope, paresthesias, or issues with coordination. The haematological review is negative for anaemia, bleeding disorders, or easy bruising. Endocrine examination confirms his controlled diabetes without thyroid illness, polyphagia, or polydipsia other than that mentioned in his recent symptoms.

Functional Assessment

Mr. J.R. is independent in all activities of daily living and self-care activities. Jarvis (2023) discusses that functional assessment gives valuable information about the patient’s ability to maintain independence and quality of life. Mr. J.R. cooks most of his meals at home and adheres to a diabetic diet regimen. The regimen offers balanced proportions of proteins, complex carbohydrates, and vegetables. He also reports eating out about 1-2 times a month and being conscious of what he orders when he does. Mr J.R. reports having whole-grain cereal and fruit for breakfast, a sandwich and salad for lunch, and lean protein and vegetables for dinner. He also only has one coffee in the morning as his source of caffeine. Mr. J.R. maintains his home independently with no physical restriction to mobility. He exercises 30 minutes of walking three times a week for physical activity and does yard work on weekends. He sleeps 6-7 hours most nights but has had decreased restful sleep over the past month due to increased urination. Mr. J.R. is oriented and alert and has good memory and problem-solving ability. He has good coping skills and an optimistic attitude in difficult health conditions. His best social support is his wife, children, and church group. He is a Christian and goes to church every week. He finds his strength in his church group and prayer. Mr. J.R. emphasizes preventive health care, good health choices, and traditional medical treatment.

Conclusion

This comprehensive health history gives an excellent picture of Mr. J.R.’s current health status as it reflects his diabetic control. The assessment reveals that even though Mr J.R. is medication compliant, there has been a change in his glycemic control recently, reflecting the need to assess treatment and adjust treatment and also to evaluate for any stressors on his condition. Re-assessment of diabetic patients continually is necessary to prevent long-term complications. The results of this evaluation will be utilized to create an individual plan of care designed to improve glycemic control, fatigue, and overall well-being through medication, lifestyle modification, and supportive therapy. This health history will also be used as a baseline when assessing Mr. J.R.’s progress and response to treatment.

Get Professional Assignment Help Cheaply

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Why Choose Our Academic Writing Service?

• Plagiarism free papers
• Timely delivery
• Any deadline
• Skilled, Experienced Native English Writers
• Subject-relevant academic writer
• Adherence to paper instructions
• Ability to tackle bulk assignments
• Reasonable prices
• 24/7 Customer Support
• Get superb grades consistently

Online Academic Help With Different Subjects

Literature

Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.

Finance

Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.

Computer science

Computer science is a tough subject. Fortunately, our computer science experts are up to the match. No need to stress and have sleepless nights. Our academic writers will tackle all your computer science assignments and deliver them on time. Let us handle all your python, java, ruby, JavaScript, php , C+ assignments!

Psychology

While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.

Engineering

Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.

Nursing

In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.

Sociology

Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.

Business

We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!

Statistics

We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.

Law

Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.

What discipline/subjects do you deal in?

We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.

Are your writers competent enough to handle my paper?

Our essay writers are graduates with bachelor’s, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.

What if I don’t like the paper?

There is a very low likelihood that you won’t like the paper.

Reasons being:

• When assigning your order, we match the paper’s discipline with the writer’s field/specialization. Since all our writers are graduates, we match the paper’s subject with the field the writer studied. For instance, if it’s a nursing paper, only a nursing graduate and writer will handle it. Furthermore, all our writers have academic writing experience and top-notch research skills.
• We have a quality assurance that reviews the paper before it gets to you. As such, we ensure that you get a paper that meets the required standard and will most definitely make the grade.

In the event that you don’t like your paper:

• The writer will revise the paper up to your pleasing. You have unlimited revisions. You simply need to highlight what specifically you don’t like about the paper, and the writer will make the amendments. The paper will be revised until you are satisfied. Revisions are free of charge
• We will have a different writer write the paper from scratch.
• Last resort, if the above does not work, we will refund your money.

Will the professor find out I didn’t write the paper myself?

Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.

What if the paper is plagiarized?

We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.

When will I get my paper?

You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

Will anyone find out that I used your services?

We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment  Help Service Works

1.      Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2.      Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3.      Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4.      Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET A PERFECT SCORE!!!