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i need help from a tutor to help me summarizing this assignment please. in a narrative format
The client is a male 67 years old, born on 18/9/1955. He is American, married, and has two dependents, his wife and granddaughter. The patient is a college graduate and a farmer. He was stable and able to give his medical history.
Present Health History
The patient has type 1 diabetes and is on oral insulin. He has a wound on his left leg that has taken a long time to heal. He is lactose intolerant and allergic to sulphuric substances.
Past Health History
He has no history of any recurring childhood illnesses. The patient was admitted to the hospital in 2014 for level 2 colon cancer treatment, and stomach surgery was performed to amputate the affected colon area. He was involved in a tragic road accident in 2007 where he lost consciousness and woke up in hospital. He got two left leg fractures which were treated through surgery and fixed with medical wires, which were later removed. The client has had only one significant disease, cancer; he was treated and attended all the assigned follow-up clinics until he was declared cancer free.
Immunization
The immunization jabs he has received are:
Tetanus- 2007 after the accident.
Polio- in childhood.
Hepatitis B- 2015 after the cancer treatment.
Influenza- 2020 and 2021 during the Covid-19 outbreak.
Mumps- in childhood
Rubella- 2002
The client has recently travelled outside the country for two months on vacation to his daughter’s place in Australia.
Date of Last Examinations
Physical examination- he attended his physical examination three months ago.
Vision- his eyes were examined one month ago, and his broken corrective lenses were replaced.
Dental- the last dental examination clinic he attended was six months ago, and he is scheduled for the next one in two weeks.
Family History
Grandparents- the client doesn’t remember their dates of birth, but he has a grasp of their medical history. His grandfather had hypertension and died of cardiac arrest, while the grandmother had Diabetes and was discovered with cervical level 3 cancer. She died months later after the diagnosis.
Parents- both of his parents had hypertension and Diabetes. His mother died at the age of 86 years of cardiac issues. His father was a chain smoker and discovered prostate cancer at 69 years; he underwent surgery and removed the infected prostate. He later died in the road accident he was also involved in at the age of 78 years.
Siblings- he has six siblings, and out of four, the three male surviving ones suffer from hypertension and Diabetes. The deceased brother died of a chest infection at the age of 51 years. The female siblings are all well and with no medical issues.
Review of Systems
General Health Status
The patient is experiencing a lot of fatigue, body weakness, and noticeable weight loss.
Integumentary
Skin- his skin has recently been itching, dries up even after applying oil, and has sores that take a long time to heal. He uses sunscreen and petroleum jelly and does not expose himself to the sun for long.
Hair- the hair is in good condition, and he is not experiencing hair loss.
Nails- the nail color is standard and not cracking.
HEENT
Head- the patient has been experiencing frequent headaches and dizziness from time to time, and he doesn’t have an injury, concussion, or loss of consciousness.
Neck- his neck is regular.
Eyes- the client can not see things at a far distance and uses corrective lenses for that and light regulation. He doesn’t have an eye injury, itchiness, tearing, discharge, pain, floaters, and halos around lights. He can not stand flashing lights since he is light-sensitive and can read well with glasses.
Ears- the last ear test he attended was one year ago. He does not have changes in hearing, pain, drainage problems, vertigo, infections, ringing, and excess wax. His hearing is perfect.
Nose, Nasopharynx, and sinuses- have no nasal problems and never nose bled. He snores and sneezes f triggered by either dust or smelly things. He has no nasopharynx or sinuses issues.
Mouth- the client has no medical problem with his mouth since he visits the dentist for check-ups often.
Respiratory
The client has had a history o smoking for 26 years, but since he quit smoking, he has not experienced any respiration problems.
Cardiovascular
The patient’s cardiovascular system is normal.
Breasts
His breasts are normal.
Gastrointestinal
The client’s appetite has not changed, and he experiences heartburn on eating spicy foods. He does not have any other problems with his digestive system. He has never had a faecal occult blood test or colonoscopy.
Genitourinary
He has no changes in his urinary system but experiences frequent urination when his insulin levels are high.
Female/Male Reproductive
The client has no scrotal or prostate problems; he is not impotent because he has children, but he undertook a vasectomy several years ago. He is fine with his sexual performance, and he underwent through prostate examination a year ago, and the results were negative.
Musculoskeletal
His musculoskeletal system is normal, and he has not done a bone density scan.
Neurological
The patient’s neurological system is perfect.
Psychosocial Profile
Health practices and beliefs/ self-care activities
He exercises by walking around his farm and does self-blood tests weekly. He brushes his teeth twice daily and undergoes examinations once a month.
Nutritional Pattern
His level of appetite is normal, and he takes three main meals a day plus one fruit snack during the day.
Functional ability
He can perform daily activities very well without aid.
Sleep/rest patterns
The patient sleeps more than six hours a night and takes a short nap during the day. He is not on sleep aids.
Personal Habits
The patient does not use drugs.
Environmental History
He lives in a rural area in his own home.
Family social Relationship
He lives with his wife and granddaughter.
Cultural Religious Influences
No cultural influences on his health.
Mental Health
The client’s mental health is perfect. He does not use any medication and takes walks to deal with his emotions.
The patient’s strength is that he follows a healthy nutrition and exercise program. He also checks his blood sugar levels without supervision. His weakness is sugar intake when he is with his granddaughter, which triggers his glucose level.

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