Biographical data, occupation, language and religion

Luna K. is a 25-year-old lady who lives in Philadelphia and works as a clerk at one of the local banks. She admits to loving her job and hence feels that any deterrence to the execution of her duties must be addressed with immediate effect. In addition to that, the client admits that while she is not engaged in marriage, she is currently seeing someone and she is hopeful that one day the relationship will lead to marriage.

Luna is an American, both by birth and by nationality. As such, her primary language is English despite the fact that she speaks a little French. Aside from the language she speaks, she is a lover of physical activities including yoga. The client has an amazing passion for healthy living and healthy eating and it is for this reason that she makes every possible attempt to improve her health.

Source and Reliability

The source of information relevant to this document is Luna herself. It is important to note that the information was provided firsthand and hence very reliable and dependable. The participated directly in divulging the relevant information that was later compiled to come up with the objectives of the assignment. It is therefore important to deduce that the information provided by the client is reliable and trusted.

Reasons for Seeking Care

The client has a number of reasons for seeking medical care. She admits to coughing hysterically especially during the night. In addition to that, Luna explains that she experiences shortness of breath, chest tightening and wheezing of the chest during breathing (Barreiro, et al 2004). According to her, her experiences are more prevalent during cold weather, at night and when she is partaking of her physical activities and exercises.

After a continued interview with the client, it was certain that she always have a feeling of fatigue especially during physical exercise, she experiences signs of allergies including sneezing, nasal congestion, headaches, sore throat and running nose. She also admits to having trouble during sleeping and always feels like her chest is congested in one way or another. During her daily physical exercises, Luna explains that she loses breath and experiences short breaths at particular times especially when she engages in a strenuous physical activity (Barreiro, et al 2004).

Culture, Society and Spiritual Influences

The client reports that her family lineage has its roots in India. While this might be the case, Luna was born and bred in the United States of America. She has, therefore, lived her entire life in the US. As a matter of fact, Luna reported that she has never visited India where her family lineage stems from. She mentioned that her failure to visit India was perhaps because there is no notable relative left in India. Aside from her origin, Luna reported that yoga, as a physical exercise giver her utter peace. Being of the Indian origin, yoga is almost inseparable with her lifestyle. This is an implication that the client loves physical activity as already mentioned.

The client spares at least two hours every day for physical exercise. The client admits that she engages in these kinds of activities without the assistance of any guide or tutor. Therefore, she engages in these activities from the comfort of her house and sometimes goes for a run in the streets around her neighborhood.

Luna reported that she loves taking part in health promotion activities. She admits that this is part of her initiative of promoting both healthy living and healthy eating. She believed that the prevalent chronic illnesses are closely attributed to the foods people eat and their lifestyles. As a counter-measure therefore, Luna is a proactive supporter of health promotion activities.

Hinduism is the religious activity that the client identifies herself with. Nonetheless, she admitted that her religious practices do not interfere with her daily routines. She accompanies her family and sometimes friends to the temple at least once a week for prayer purposes. Her involvement in such religious activities helps her provide purpose to life.

History of Present Illness and Present Health

The client’s present health concern is difficulty in breathing especially after strenuous physical exercise. In addition to that, the client admitted that she experiences wheezing and hysterical coughing during cold weathers and sometimes these symptoms are accompanied by headaches and fatigue. Also, the client admitted to experiencing fatigue in body joints especially when the above-mentioned symptoms escalate.

Luna reported that she began experiencing these symptoms about four months ago. She, however, did not seek immediate medical attention because the symptoms were mild and not life-threatening at that moment. With time, these symptoms became more prevalent, persistent and almost life-threatening (Pearce, et al 2007). It is for this reason that Luna decided to seek advice from a qualified medical practitioner with the aim of ascertaining the reason for her discomfort and possible solutions to the discomfort.

Past Health

General Health

The client has in the past lived a comparatively healthy life devoid of weight loss, pain in the joints and other symptoms that might be attributed to illness. Additionally, other than the past four months, the client has had no past history of wheezing of the chest and difficulty in breathing.

Childhood Illnesses

Despite having experienced other ordinary illnesses like malaria and pneumonia in her childhood, Luna reported that she had not experienced such symptoms like difficulty in breathing in her childhood.

Accidents Or Injuries

Luna admitted that she had had several childhood injuries including a road carnage that broke her left arm at the age of ten. She was hospitalized for a month after which she made several visits to the hospital for a checkup. She was ultimately declared fully recovered from the broken arm (Barreiro, et al 2004).

Serious Or Chronic Illnesses That Include Severe Past Acute Illnesses

Luna reported that she had never been diagnosed with any serious or chronic illnesses in the past. She admitted that this is the reason why she did not see the immediate urgency of seeking medical attention when she began experiencing the above-mentioned symptoms four months ago.

Hospitalizations

The only major hospitalization of the client only happened when she was involved in an accident that left her left arm broken. After having stayed in the hospital for one month followed by subsequent checkup visits, she was declared fully recovered.

Operations

The client had undergone surgery only once in her lifetime. The surgery was carried out when she was involved in road carnage at the age of ten that left her left arm broken. Aside from this single case, the client has never had any other surgery again.

Immunizations

At a tender age of between months to two years, the client received immunizations against polio, chicken pox, and smallpox. She has never had any other immunization since then.

Last Examination Date

The client reported that her last medical examination was six months ago. She admitted that this happened during her general medical examinations that she does every six months.

Allergies

The client reported that she had been allergic to cold weather in the past. However, her allergy to such conditions has never been life-threatening before.

Current Diet, Special Diets Or Dietary Issues

Luna reported that she had not dietary issues at all. She did not have a special diet and neither was she allergic to certain foods.

Current Medications

The client reported that she was not under any form of medication at the time of the interview. She further ascertained that this included contraceptives.

Family History

Maternal: Brain cancer in aunty and niece

Paternal: Luna reported that her grandmother suffered from high blood pressure. She also admitted that her grandfather was diagnosed with diabetes mellitus which he succumbed to two years ago.

Review of Systems

Eyes

The client always has vision problems whenever her symptoms persist. according to her, she experiences mild pains in the eyes whenever the above-mentioned symptoms occur. While this is always the case, Luna admitted that her vision problems have never been attributed to any other environmental conditions other than her chest and breathing problems (Barreiro, et al 2004).

Neck and Head

Luna always experiences fatigue in the neck especially when her other symptoms emerge. She says that such fatigue is accompanied by mild headaches that rarely subside despite taking counter-measured like painkillers. She described her neck pains as mild but persistent with other related symptoms like difficulty in breathing.

Chest and Lungs

Luna described that her chest and lungs were the most affected organs of her body as a result of her illness. She admitted that she always feels suffocation and mild to severe pains in the chest and lungs. Whenever she had difficulty in breathing, she reported that the wheezing sounds that could be heard from inside her chest were accompanied by severe pains in the chest. As a result of these assessments, it was certain that her lungs were affected too by the symptoms.

Abdomen

The client admitted to experiencing mild to severe pains in the upper abdomen. The area of the upper abdomen houses the lungs. As already noted before, the client had problems with breathing and hence this can be attributed to a lung problem.

Other Physical Body Parts

Apart from the above mentioned notable problems, the client admitted that she did not experience pain in other physical body parts like legs and arms.

Functional Assessment

According to the information and the physical examinations of the client, it can be deduced that the client suffers from asthma. It should be noted that asthma can be described as a chronic condition that either inflames of narrows the airways. Inflamed airways are always very sensitive and as a result, react to environmental debris that comes into direct contact with them. In turn, they narrow further thereby hindering effective breathing (Barreiro, et al 2004).

Patients who suffer from this condition always experience difficulty in breathing and always experience wheezing. In addition, they cough hysterically as a way of reacting to the foreign particles that come into contact with the airways. Sadly, asthma has no known cure as at today. However, the doctors normally advise asthma patients to avoid asthma triggers. Subsequently, these patients are given medications that prevent asthma symptoms.