Personal Health Case Study: Mr. Chan Man
1. Background information
Mr. Chan Man is a 19-year-old single male. His BMI is 18.9, which is in the normal range: 18.5 to 24.9 (Bickley, 2012), with height 185 cm and weight 65 kg. He lives with parents. He is now working at CHIPS cafe. He exercises about one to two hours every day.
2. Chief complaint
He felt tired and a bit dizzy and had intermittent stomach ache in these 4 days.
3. History of present problem
Tiredness and dizziness were due to lack of sleep. He slept about 4 to 6 hours a day, sometimes even 3 hours. He had irregular eating schedule and sometimes skip meals so he had stomach ache.
4. Health history
a. Personal health history
He had had asthma and was cured after he learnt swimming at 10 years old. He had the appendicitis …show more content…
5. 12 activities of living
Maintaining a safe environment
He may not able to maintain a safe environment. Since he works in kitchen which is quite dangerous, it requires high level of awareness to prevent accidents from happening. But as he feels tired and dizzy due to lack of sleep, he may be difficult to focus and lose his awareness. Thus, accident may occur, such as burn by hot oil and fire.
Communicating
The problems do not physically affect Mr. Chan’s communication. He can still talk and listen to others. But the discomfort of body and pain of stomach may hinder the willingness to communicate. He speaks fluent Cantonese and Putonghua so he can communicate well using these languages. Also, he is oriented to time and place which shows he is conscious in communication.
Breathing
He has normal breathing except the time he has stomach ache. Without stomach pain, his breathing rate is 13 breaths per minute (bpm), in the normal range: 12 to 16 bpm (Johns Hopkins Medicine, n.d.). No cough or expectoration. No pain during breathing and the breathing pattern is regular. And he does not have any difficulty in breathing. But when he has stomach ache, he feels difficult to breath and the breathing pattern is irregular. And pain appears during breathing, especially deep breathing. Also, he is non-smoker so the risk of potential problem is …show more content…
Chan has irregular eating habits and he skips meals all the times but he intakes enough energy from food as he has normal BMI. And he drinks about 2.3 L water every day which is recommended (Natural Hydration Council, n.d.). Assistance is not required for eating or drinking. He does not have any difficulty in swallowing food. But the lack of sleep and stomach ache may affect his appetite.
Eliminating
Mr. Chan does not have problem in eliminating. He defecates every day without any pain or discomfort. He does not have incontinence or hemorrhoids. No dysuria and nocturia. He urinate once 3 to 4 hours under normal range (Shu, 2011) with normal amount, color and odor. He does not have usual patterns, such as stoma care and use of laxatives or
Mr. Chan Man is a 19-year-old single male. His BMI is 18.9, which is in the normal range: 18.5 to 24.9 (Bickley, 2012), with height 185 cm and weight 65 kg. He lives with parents. He is now working at CHIPS cafe. He exercises about one to two hours every day.
2. Chief complaint
He felt tired and a bit dizzy and had intermittent stomach ache in these 4 days.
3. History of present problem
Tiredness and dizziness were due to lack of sleep. He slept about 4 to 6 hours a day, sometimes even 3 hours. He had irregular eating schedule and sometimes skip meals so he had stomach ache.
4. Health history
a. Personal health history
He had had asthma and was cured after he learnt swimming at 10 years old. He had the appendicitis …show more content…
5. 12 activities of living
Maintaining a safe environment
He may not able to maintain a safe environment. Since he works in kitchen which is quite dangerous, it requires high level of awareness to prevent accidents from happening. But as he feels tired and dizzy due to lack of sleep, he may be difficult to focus and lose his awareness. Thus, accident may occur, such as burn by hot oil and fire.
Communicating
The problems do not physically affect Mr. Chan’s communication. He can still talk and listen to others. But the discomfort of body and pain of stomach may hinder the willingness to communicate. He speaks fluent Cantonese and Putonghua so he can communicate well using these languages. Also, he is oriented to time and place which shows he is conscious in communication.
Breathing
He has normal breathing except the time he has stomach ache. Without stomach pain, his breathing rate is 13 breaths per minute (bpm), in the normal range: 12 to 16 bpm (Johns Hopkins Medicine, n.d.). No cough or expectoration. No pain during breathing and the breathing pattern is regular. And he does not have any difficulty in breathing. But when he has stomach ache, he feels difficult to breath and the breathing pattern is irregular. And pain appears during breathing, especially deep breathing. Also, he is non-smoker so the risk of potential problem is …show more content…
Chan has irregular eating habits and he skips meals all the times but he intakes enough energy from food as he has normal BMI. And he drinks about 2.3 L water every day which is recommended (Natural Hydration Council, n.d.). Assistance is not required for eating or drinking. He does not have any difficulty in swallowing food. But the lack of sleep and stomach ache may affect his appetite.
Eliminating
Mr. Chan does not have problem in eliminating. He defecates every day without any pain or discomfort. He does not have incontinence or hemorrhoids. No dysuria and nocturia. He urinate once 3 to 4 hours under normal range (Shu, 2011) with normal amount, color and odor. He does not have usual patterns, such as stoma care and use of laxatives or