Medical Record Patient Name and ID: United States, 07041776
Age: 239 Years
Medical History: Patient has had a very long life. Throughout the lifetime, patient has been diagnosed with innumerable diseases and disorders.
Main Complaints: Patient feels generally unwell. Patient would like to improve overall health. Though patient has many medical problems, patient has come here today hoping to address a few select issues. To start, patient wishes to address the effects mental illness and substance use have on their life. Furthermore, patient has been facing increased struggle with their upper respiratory system as of late. Patient has also been struggling to fully manage symptoms related to diabetes. Finally, patiently has recently been told that ischemic heart disease (hardening of the arteries) is one of the most pressing issues they currently must deal with, as it alone may have a large effect on their life.
Patient Habits and Lifestyle: Patient reports occasional smoking. Patient estimates having a few drinks a week, and reports having tried some illicit drugs. Patient reports having occasional problems with money, which affect patients ability to regularly see a doctor/receive treatment, access adequate and healthy food, live in safe housing, and find clean water. Patient reports various life stressors, and a family history of mental illness.
- Patient will need to address issues of economic and social inequality. Access to care is of the utmost importance in treating any condition. While progress has been made toward increasing access to care, more must be done. The biases of medical professionals must also be addressed. This will help with all of the patient’s complaints.
- Effort must be made to ensure patient always has access to safe drinking water. We have seen thousands be poisoned in the water crisis in Flint, Michigan. This must not be repeated.
- Efforts should be made to combat pollution on a global and national scale. Clean air, water, and land have numerous health benefits, while pollution can affect many aspects of health. Efforts should be made to investigate alternative fuel sources, as this will prevent carbon emissions. Safety standards must be enforced in mining and related operations. Education on pollution and individual efforts to prevent it should also be implemented. On the global scale, patient must work with others to generate international effort to combat climate change and stop the harming of our planet. Work should be done to ensure people do not have to live in areas where they have daily exposure to hazardous chemicals. Special attention must be paid to people with lower incomes, as they are more likely to live in these conditions.
- Adequate amounts of healthy food are essential. The Supplemental Nutrition Assistance Program (SNAP) must remain in place. Businesses should be encouraged to build grocery stores in food desert designated areas, to allow those normally unable to access things such as fresh produce to do so. Nutritional education in schools would also be beneficial. School lunch programs and summer community center lunch programs for children are an important step in ensuring children have access to healthy food. An increased effort to follow dietary guidelines, and promote ways for people with lower incomes to follow them, is also essential. This will be especially helpful in treating the complaints of ischemic heart disease and diabetes.
- Investment in education is very important. It has innumerable benefits for a person’s health, including lower mortality rates and knowledge of how to lead a healthier life.
- I recommend the patient invest in high-quality addiction treatment. Patient reported past participation in AA, but this is not necessarily an effective method. Given this, patient should focus more on investigating different treatments. Investing research money into what works and what doesn’t would be most beneficial. In addition, harm reduction strategies deserve a serious look. While these will not necessarily stop alcohol or drug use, they may be able to alleviate some negatives, including decreasing the number of people in prison for drug related offenses and decreasing deaths or impairments related to drug use. To help prevent the same abuse problems patient has in patients children, patient should investigate evidence based prevention and education programs.
- Patient should make every effort to educate others about mental health. Education has the ability to reduce stigma towards mental illnesses, and therefore make treatment more accessible. Efforts to decrease homelessness and improve mental healthcare within the justice system are important, because homeless and being in prison are risk factors. Further efforts must be made to ensure parity in mental health coverage in insurance plans. Various prevention efforts should also be adopted. These should include education about warning signs and risk factors, stress reductions programs, self care education, and how to maintain a healthy lifestyle.
Prognosis: Becoming healthier is no easy task. The patient has many other health problems not addressed in this appointment. These recommendations are preliminary, and many more will need to be made in the future. Solutions proposed here are not the only ones, so patient should be sure to not view these as the end-all be-all. Second opinions are also recommended. Hard work and commitment are needed to implement any major changes in health, and this cannot be done alone. Should patient commit time, money, and effort, patient will see changes in health.
Doctors Note: I would encourage the patient to also consult my various colleagues about ways they better health can be achieved, not just for the patient in question but also for other people the patient knows.