Far Eastern University

Institute of Health Sciences and Nursing

Health History
Documentation

Submitted by: Eizen Kyle C. Villamor

Section & Group: SEC 3 GROUP 8

 Far Eastern University

Institute of Health Sciences and Nursing

I. DEMOGRAPHIC PROFILE

Name: C.E.P.V.

Address: Unit 11 Montvill Place Quirino Novaliches Quezon City

Age: 19 years old Birth Date: July 28, 2004

Gender: Male Birth Place: Metro Manila

Religion: Roman Catholic Race/Ethnic Origin: Asian, Filipino

Occupation: Student Educational Attainment: College

II. Reason for Seeking Healthcare/ Chief Complaint

The patient feels healthy and presents no specific complaints, seeking a general
health assessment checkup.

III. Past Health History

The patient received Pfizer vaccination in March of 2022. He had BCG and DPT
immunization administered at birth being the only other immunizations recalled.
Childhood illnesses included an inguinal hernia at the age of 3, while a COVID-19
exposure incident occurred in 2021 necessitating a two-week self-quarantine period
for the family. Heredofamilial diseases such as asthma, diabetes, and
hypothyroidism are noted. There is no history of accidents or injuries, except for a
one-week hospitalization related to hernia in 2007, which was addressed via
herniorrhaphy. No recent out-of-town travels in the past six months.
IV. Family History

Genogram

Brief summary: On the paternal side, hypertensive and diabetes are noted as
heredofamilial diseases, while asthma and hypothyroidism are prevalent on the
maternal side. Moreover, the patient's grandfather succumbed to thyroid
cancer at the age of 58. It's worth mentioning that despite these genetic
predispositions within the family, the patient is currently free from these
conditions.
Analysis: Individuals with comorbidities such as asthma, hypertension,
hypothyroidism, and diabetes face complex interactions between these
conditions, which can impact their overall health and well-being. While each
condition affects different systems in the body, there are potential overlapping
effects and interactions to consider (Shuvo, S. et al. 2023). For instance, asthma
medications like corticosteroids may raise blood pressure, and poorly controlled
diabetes can intensify asthma symptoms due to compromised immune function
(Uppal, P. et al. 2023). Hypothyroidism can indirectly contribute to hypertension
through factors such as weight gain and elevated cholesterol levels, while also
potentially affecting glucose metabolism and increasing the risk of diabetes
(Biondi, B. et al. 2019). Managing these comorbidities requires a comprehensive
approach, including medication management, lifestyle modifications, and
regular monitoring.

Reference

Shuvo, S., Hossen, T., Riazuddin, M., Hossasin, S., Mazumdar, S., Parvin, R., & Elahi,
T. (2023). Prevalence of comorbidities and its associated factors among type-2
diabetes patients: a hospital-based study in Jashore District, Bangladesh.
PubMed Central

Uppal, P., Mohammed, S., Rajashekar, S., Ravindran, S., Kakarla, M., Gambo, M.,
Salama, M., Ismail, N., Tavalla, P. & Hamid P. (2023). Type 2 diabetes mellitus
and asthma: pathomechanisms of their association and clinical implications.
PubMed Central

Biondi, B., Kahaly, G. & Robertson, P. (2019). Thyroid dysfunction and diabetes
mellitus: two closely associated disorders. PubMed Central
V. Gordon’s Health Assessment

A. Health Perception – Health Management

Narrative Form: The patient has a BMI of 16.4 is aware of his underweight
condition. They understand the importance of eating regularly, proper nutrition,
staying hydrated, and exercising. Notably, the patient does not smoke or vape.
They occasionally consume alcohol, limiting themselves to around five shots of
liquor per month for social bonding with friends and family. The patient also
routinely conducts testicular examinations as a proactive measure for their
health.

Interpretation: Deviation from normal

Analysis: According to Tomaszewski et al. (2013) The usual body fat content of
boys at the age of 19 is 23.7 with a BMI of 24.6 indicating deviation of body mass
index for the patient. According to Serra-Majem (2016) evidence has shown that
the mortality risk of people who are even mildly underweight has increased and
severe cases are at even greater risk and might cause growth retardation as a
result of poor diet or recurrent infections which tend to be at greater risk for
illness and death. The patient recognizes their underweight condition which
indicates self-awareness index for the patient and is a primary factor influencing
the decision to engage in health protective behaviors. However, perceived
health is not always congruent with actual health status. (Lee, 2019)

Reference:

Tomaszewski, P. & Stupnicki, R. & Milde, K. (2013). Body mass index – proposed
norms for children and youths. Papers on Anthropology.

Lee, K., Feltner, F., Bailey, Alison., Lennie, T., Chung, M., Smalls, B., Schuman, D., &
Moser, D. (2019). The relationship between physiological states and health
 perception in individuals at risks for cardiovascular disease. Psychol Res Behav
Manag

Serra-Majem, L. & Ngo, J. (2016). Malnutrition: concept, classification and

magnitude. Encyclopedia of Food and Health

B. Nutritional – Metabolic Pattern

Narrative form: The patient's diet and preferences mainly consist of red and white
meat, with occasional servings of vegetables. They often eat only two meals a
day, typically skipping breakfast, and consume 1-2 servings per meal.
Additionally, the patient consumes around 70 ounces of water a day. However,
the patient has a shellfish allergy and develops allergic wheals on their chest
and abdomen; he takes cetirizine as medication afterward. From time to time,
the patient buys or cooks for himself or for his whole family. His main fluid
intake includes water and tea, specifically chamomile for sleep and yellow tea
for energy. The patient also takes supplements such as melatonin for sleep and
vitamin C for skin care which are both self-prescribed. Despite his dietary habits,
the patient's weight is consistently sustained, with a body mass index of 16.4.
Notably, the patient has impacted teeth, specifically misalignment due to
wisdom teeth.