Harley Monroe
PATIENT INFORMATION
Name: Harley Monroe
Date of Birth: 09/13/1953
Address: ████ ███████ ████, Fredericksburg, VA
Phone Number: ████████████
Weight: 145 lbs
Height: 6'1"
Blood Type: [Not provided]
Name: Aisling Monroe
Relationship: Adoptive Brother
Phone Number: ████████████
Address: ████ ███████ ████, Fredericksburg, VA
Chronic Conditions: Sustained severe trauma to both hands in a motor vehicle accident in late adolescence. Multiple fractures involving the metacarpals and carpal bones; described by attending physicians as near-total shattering of both hands. Surgical intervention performed to stabilize fractures with internal fixation. Patient experiences ongoing joint pain, stiffness, and diminished fine motor skills. Diagnosed with bronchial asthma in childhood. Depigmentation of skin and hair consistent with vitiligo noted in early adolescence. Patient demonstrates signs of melancholic depression and long-standing nervous condition. Behavioral traits observed since childhood are noted as socially atypical. Congenital variation in sex development recorded at birth.
Previous Surgeries: Reconstructive orthopedic surgery on both hands following high-impact trauma from motor vehicle accident. Surgical stabilization included internal pins and extended recovery with occupational therapy focused on hand function. Additional outpatient therapy for pain management and range of motion support.
Hospitalizations: Extended hospitalization for bilateral hand injuries and post-surgical recovery. No additional hospital admissions on record.
Allergies: Reports hypersensitivity to certain fresh fruits and tree nuts. Environmental reactions triggered by cats, dogs, and common pollens.
████████ █████████ (Father)
Chronic Conditions: Mild asthma in childhood.
Previous Surgeries: Appendectomy at age 15.
Allergies: Penicillin allergy noted.
Mental Health History: Nervous disposition and general anxiety reported in adult life.
Status: Deceased.
██████ █████████ (Mother)
Chronic Conditions: Seasonal allergic rhinitis.
Previous Surgeries: None reported.
Allergies: Shellfish allergy; mild bee sting reaction.
Mental Health History: History of emotional strain during college years; counseling pursued privately.
Status: Deceased.
Current Medications: Prescribed tranquilizers as needed (Librium) for anxiety; prescribed theophylline for asthma management. No regular antidepressant at present.
Medication Compliance: Generally compliant; periods of emotional distress may interrupt routine.
Medication Side Effects: Reports occasional upset stomach and lightheadedness while taking prescribed sedatives.
Patient is advised to keep a written journal of mood changes and avoid high-stress environments. Emergency contact should be notified in the event of a major episode of emotional instability. Asthma should be managed with the prescribed bronchodilator, to be carried at all times. In case of a severe asthma attack or mental health crisis, immediate transport to nearest hospital is advised.