Health History for Norman Golding

Running head: HEALTH HISTORY 1
Health History
Name
Institution

HEALTH HISTORY 2
Health History for Norman Golding
Date: 7:10:2017
Examiner: Dr. Mell Banks
1. Biographical Data
Name: Norman Golding
Birth Date: 11.11.1979
Age: 38
Gender: Male
Place of Birth: Texas, USA
Marital Status: Married
Race/ Ethnic origin: White
Telephone number: [phone]
Occupation: Mechanical Engineer
Employer: Government parastatals
2. Source and Reliability
Patient, who is reliable as well as the hospital's records
3. Reason for Seeking care
The admission will be the second so far for Norman who has a history of hypertension.
The patient complains of chest pain lasting for 12 hours.
4. History of present illness
Norman has a long history of a condition known as hypertension. The condition is
normally controlled through diuretic therapy. His first admitted was in 1998 with complaints of
internal mid-sternal chest pain. The X-ray conducted on him indicated mild pulmonary

HEALTH HISTORY 3
congestion with cardiomegaly. He was discharged following a series of treatment in the hospital
like Lasix and digoxin for congestive heart failure. Since that time, his medical record has been
closely followed by his cardiologist.
The patient was well until 8 pm yesterday night when he noticed the onset of an aching
pain in his chest while helping his wife with minor duties. He described the pain like a toothache
like and it was noted to increase with exertion. No other symptoms were indicated. He took two
tablespoons of antacid but did not get any relief, the pain gradually increased. After roughly six
hours, his wife gave him an aspirin and brought him to the emergency room. The
electrocardiogram indicated sinus tachycardia at 110 as well as occasion ventricular paroxysmal
contractions. He was immediately placed on thrombolytic therapy and cardiac medication.
The current treatment includes Tylenol 2 tabs daily, Enalapril 20mg twice daily, Digoxin
0.125mg once daily and Lasix 40mg once every other day.
5. Past health history
General health: The general health description can be considered as relatively good.
Childhood illness: Norman had usual childhood illnesses
Immunizations: Flu vaccine yearly
Allergies: Allergic to penicillin. This was developed after an injection 15 years ago and
reacts through causing a diffuse rush.
Transfusions: 3 units received in 1990 for GI hemorrhage, the transfusion complicated by
a Hepatitis B infection
Previous hospitalization: 1994 Gastrointestinal hemorrhage and in 7/1998 chest pain
6. Family and Personal History
Norman Golding is lives with his wife and daughters in Texas.

HEALTH HISTORY 4
He works as a mechanical engineer in a local government firm
Lifestyle habits: Does not take alcohol or cigarettes.
Follows a strict diet
He has never been outside the United States
Present environment: Normal lives in a three-bedroom apartment on the third floor.
Financial stability: Norman is financially stable and has medical coverage insurance
Psychosocial aspect: Generally, Norman is an alert and active man despite his condition.
Family history:
The mother of the patient died at the age of 34 from diabetes, and hence he was brought
up by his aunt. His father died following a car accident at the age of 56. The patient also had a
sister who died nine years ago as a result of seizures and pneumonia and another brother who
died in childbirth. Norman has three daughters (ages 16, 12, 10), his daughters are all healthy.
His background check shows a history of heart-related diseases as well as diabetes.