Health Assessment - Case Study Example

Health assessments A plan of health care that affords one a full control over health for the future, health assessment is an attempt to identify the specific needs of a patient and how these needs are going to be met head-on by health agents. It rests on the belief that early detection of illness results to easier management of one’s health problem and more successful treatment. The following sections would detail the relevant information of two individuals’ health conditions, who are referred to in this paper in their first names. The format that is adapted is that of the functional health pattern (assessment). A. Luz (Patient A) 1. Biographical data, age and gender Luz is a sixty (60) years old woman. She’s a long time widow and a mother of three adult daughters. She lives in Sydney. 2. Reason for seeking health care Luz came for medical check-up as she complains of chest pain for the last seven (7) days. She, however, was not confined in the hospital. 3. History of present illness For the first time, Luz felt the chest pain that she complains about. She claims that she was healthy until she felt the sting on her chest. She narrates that, at first, she felt some abrupt onset of her chest pain lasting for some few seconds to almost a minute. It begins in the left parasternal area and creeps towards her neck. She remembers that she felt that pain for the first time while she was tending her garden in the middle of the day. It was after she had worked for more or less forty-five (45) minutes. As she felt the pain, she also got tired and felt discomfort. She also experienced shortness of breathing, although she did not sweat, became nauseous, or vomited. She negotiated her way inside her domicile to take a rest. The pain lasted for five (5) to ten (10) minutes. Her first bout with chest pain was followed by two (2) more episodes of pain – which were consistently similar in location and quality. Two days after her first chest pain, as she was walking her dog around the neighborhood, she felt again the pain. Thus, she decided to stop walking and take some rest on a bench along her way. Four days after, she was about to sleep when felt the same pain. This time, it lasted for some thirty (30) minutes – which prompted her to call for an ambulance. She has said that, aside from resting, she tried no specific measure to bring her respite from her pain. She knows no other associated symptoms during her experiences of pain, including giddiness or palpitations. She experiences breathing difficulty, but tells no exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. The pain is unchanged by any body movement. She says she cannot associate the pain with food. She has not been told, too, that she has a heart problem; and she does not track her cholesterol level. She described no history of cancer or lung disease. She does not have pain or cramping of lower leg. She does not smoke, and has no diabetes. But, she was diagnosed with hypertension some three (3) years ago and had a total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) for uterine fibroids six (6) years ago. She was diagnosed, too, eight (8) years ago of peptic ulcer disease. She is not on hormone replacement therapy. Her family has premature coronary artery disease (CAD). She also reported allergy to penicillin. 4. Medications i. Prescribed She can no longer remember the medication that she took for her hypertension. She stopped taking the medication after she experienced drowsiness. She took cimetidine (brand name: Tagamet) for three months after her peptic ulcer was discovered. ii. Over the counter She takes Advil, an over-the-counter (OTC) ibuprofen, for her headache (QOD or every other day), and Tylenol – a pain reliever – for her lower back pain. iii. Illicit (including alcohol and nicotine) She does not consume illegal drugs. She does not smoke. But, she’s accustomed to one (1) or two (2) bottles of beer on weekends, or a glass of wine at least once a week with dinner. 5. Family history Her father was 54, when he died of heart attack. Her mother is now 79, alive and well. She has one brother and three sisters. There is a positive family history of hypertension, but no diabetes or cancer. 6. Review of body systems i. HEENT (Head, Ears, Eyes, Nose, Throat) She complains of no headache because of change in vision. She has no nose or ear problems. She has no sore throat. ii. Cardiovascular She shows no sign of visible of pulsation, heaves, lifts or vibration. iii. Gastrointestinal She does not complain of dysphagia, nausea, vomiting or change in stool pattern, consistency and color. But she notes of epigastric burning pain, at least a couple of times per month, occurring primarily at night. iv. Genitourinary She does not complain of dysuria, nocturia, polyuria, hematuria or vaginal bleeding. v. Musculoskeletal She complains of lower back pain, approximately once every week after she tends her plants in her garden. She complains of no other muscle aches. vi. Nuerological She complains of no weakness, numbness or incoordination. vii. Physical examination a. General Luz appears alert, cooperative and oriented. b. Vital signs Her blood pressure was 168/98 (stage II, high blood pressure), her pulse 90 (which is two notches higher than the normal pulse rate of women), respiration rate is 20 (per minute, which is normal), and temperature 37 degrees (normal, or without fever). She’s 5’4, and weighs 135 pounds (i.e., her weight is just right for her height). c. Skin Her skin’s appearance, texture and temperature are normal. d. HEENT Luz’ scalp is normal. Her pupils are equally round, 4 mm, reactive to light and accommodation, sclera and conjunctive normal. There is no vessel with hemorrhage, according to fundoscopic examination. Normal, too, are her tympanic membranes and external auditory canals. Her nasal mucosa appears normal. Her oral pharynx is normal and without erythema or exudates. Tongues and gums are normal. e. Neck Luz’ neck easily moves without resistance. There is no abnormal adenopathy in the cervical and supraclavicular areas. Her trachea is midline and her thyroid gland is normal without masses. Carotid artery upstroke is normal bilaterally without bruits. Jugular venous pressure is measured 8 cm with patient at 45 degrees. f. Chest Her lungs are clear to auscultation and percussion bilaterally except for crackles heard in the lung bases bilaterally. The point of maximum impulse (PMI) is in the fifth (5th) inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is audible best at the second right inter-costal space, radiating to the neck. A third (3rd) heard sound is heard at the apex. There is no fourth (4th) heart sound or rub heard. Cystic changes are noted in the breasts bilaterally, but there is no mass or nipple discharge. g. Abdomen Her abdomen appears symmetrical without distention. Bowel sounds are normal in quality and intensity in all areas. A bruit is heard in the right para-umbilical area. There is no mass or splenomegaly noted. Liver span, by percussion, is 8cm, which is an average (see Wolf 1990). h. Extremities The extremities of the patent bear no cyanosis, clubbing or edema. Her peripheral pulses in the femoral, popliteal, anterior tibial, dorsalis pedis, brachial and radial areas are normal. i. Nodes There are no palpable nodes in the cervical, supraclavicular, axillary or inguinal areas. j. Genital/rectal Her rectal sphincter tone is normal. There is found no rectal masses or tenderness. Her stool is brown and guaiac negative. Pelvic examination shows normal external genitalia. Speculum examination reveals normal vagina and cervix. Bimanual examination discloses no palpable uterus, ovaries or masses. k. Neurological Cranial Nerves (CN) II-XII are normal. Upper and lower extremities are normal. Gait and cerebellar functions are also normal. Reflexes are normal and symmetrical bilaterally in both extremities. She appears lucid, answers questions appropriately and shows interest in knowing more about her chest pain. Summary of assessment By way of summarizing the assessment of Luz, or Patient A, the problems that may be essential to take note are the following: chest pain, FH (family history) of early ASCVD (arteriosclerotic cardiovascular disease), early surgical menopause, dyspanea, recent onset HTN (high blood pressure), abdominal bruit, systolic ejection murmur, epigastric pain, history of peptic ulcer disease, lumbosacral back pain, OTC (over-the-counter) non-steroidal analgesic use, cystic changes of breasts, and penicillin allergy. Zeroing in on the chest pain – or the pain for which Luz has sought medical care – it may constitute a diagnosis to believe that it is with features of angina pectoris (see Siklos 1999, pp. 1-18) . Following from the patient’s description of dull, aching, exertion related substernal chest pain, it potentially suggests ischemic cardiac origin. Luz’s family history of early (arteriosclerotic cardiovascular disease), hypertension and early surgical menopause are related risk factors for development of coronary artery disease. When these factors are all factored in, angina pectoris is the most likely diagnosis. And, hospitalization is indicated. In fact, other diagnoses may be made to explain Luz’s chest pain; but, they are less likely. GERD (gastroesophageal reflux disease) may happen at night, but it is usually associated neither with exertion nor with gastrointestinal symptoms such as nausea, vomiting or abdominal pain (see Marks [n.d.]). The presence of dyspnea might point to pulmonary component of Luz’s pain, but she has no fever, cough or pulmonary infecton. As a result, Luz needs to be carefully monitored for any increased chest pain, which may indicate impending myocardial infarction or heart attack. She may be given aspirin to decrease her risk of myocardial infarction, and nitrates to decrease the risk of occlusion, treat her symptoms of pain and help lower her blood pressure. Should she be unresponsive to nitrates, she may be given an analgesic such as morphine. Luz should also have her cholesterol monitored, be started on an appropriate exercise regimen and weight loss program, and be made to follow low-fat diet. If her cholesterol is high, she may be given cholesterol-lowering medicine. It will also help to schedule her for cardiac catheterization, together with a ventriculogram to assess cardiac size and presence of wall motion abnormalities (see Kulick & Lee [n.d.]). For her dyspnea, she may begin diuretics – which will treat her high blood pressure, too (see NLHEP 2000). Other appropriate laboratory work would include BUN (blood urea nitrogen) /creatinine to assess kidney function, electrolytes and baseline ECG (electrocardiogram). B. Patient B 1. Biographical data, age and gender Melissa is a 55-year old lady, born and currently resides in Sydney. She’s married and lives with her husband of thirty (30) years. She is diagnosed of diabetes Type II since five (5) years ago. 2. Reason for seeking health care Diabetic, she complained of vomiting. But, her major reason for seeking medical care is her extreme weakness and dizziness. She reports that she’s been in bed for three (3) days. 3. History of present illness Five(5) years ago, she was diagnosed with diabetes mellitus type-II. She is said to have peripheral vascular disease, too. She does not follow her diet, exercises not regularly and at times skips her oral diabetes medicine, Glucophage (Metformin Hydrochloride). Over-all, despite the diagnosis that she has diabetes, she does not know how to care for her disease. 4. Medications i. Prescribed She takes Glucophage with dosage of 10-mg in the morning at breakfast and 5-mg after dinner. ii. Over the counter She reports taking no OTC or over-the-counter drug. iii. Illicit (including alcohol and nicotine) She used to smoke heavily, but has quitted since she was diagnosed with diabetis. She denied taking drugs and taking liquor. 5. Family history She’s the youngest of eight children of a poor family. She was separated from her parents and siblings at an early age, and never saw her family until she was grown. She has been married for thirty (30) years. She attends Baptist Church. She has five adult children, with three residing very near to her residence. 6. Review of body systems i. HEENT (Head, Ears, Eyes, Nose, Throat) Despite her reported dizzy feeling, she reports no headache. She admits occasional blurring of vision. She has no nose or ear problems. She has no sore throat. But, she reports of bland taste. ii. Cardiovascular There is no detected pulsation, heaves, lifts or vibration. iii. Gastrointestinal She complains of vomiting. But her stool’s pattern, consistency and color do not change. iv. Genitourinary She does not complain of dysuria, nocturia, polyuria, hematuria or vaginal bleeding. v. Musculoskeletal Her muscles are strong, and her upper extremities have full range of motion. She walks steadily, but complains of radiating pain in her lower extremities. Her left great toe is discolored. She shrugs her shoulders and moves her head to right and against resistance without weakness – cranial nerve (CN) XI appears intact. vi. Nuerological She complains of weakness, numbness of lower extremities, but she is coordinated. vii. Physical examination a. General physical survey She appears alert, recollected and cooperative. Her face muscles appear tense. b. Vital signs She stands 5’3 and weighs 190 lbs (i.e., she’s big for her height). Her oral temperature reads 37 degrees (normal termperature), pulse is 100 (high pulse rate), blood pressure is 130/86 (high normal). Her respiration rate is 19 (per minute, which is normal). c. Skin Her skin is light brown color that is consistent throughout her body, and is smooth. She shows signs of dehydration. She has small discolored spot on left great toe, but has no edema. d. HEENT She wears glasses for reading, and sometimes her vision is blurred. Except for this, her eyes do not get itchy, have no discharge, are not reddening, and not traumatized. She does not wear hearing aids, and appears to have usual hearing capacity. She claims no decrease in smell. Her nose does not bleed, or discharge. She reports that her food never tastes good, so she adds more salt to it. Otherwise, her tongue is normal. Her gums are showing signs of bleeding. Her scalp is normal. e. Neck Her neck moves without resistance. She has no abnormal adenopathy in the cervical and supraclavicular areas. Her thyroid gland and carotid artery upstroke are normal. f. Chest Melissa’s breasts are symmetrical in size. She has no masses, lesions, tenderness on palpation bilaterally, dimpling or inverted nipples. g. Abdomen Her abdomen shows no distention, and is symmetrical without masses or lesions. Her umbilicus midline is neither swelling nor discolored. Bowel sounds are present in all four quadrants. She vomits for one day. There is no tenderness on light and deep palpation. h. Extremities Her arms are equal in size and symmetry, cool and dry to touch bilaterally, no edema or lesions. Her legs are equal in size and symmetry. She has small discolored area on left great toe. The skin of her toe is cool to touch, dry and has no edema. Toenails are fairly soft. i. Nodes There are no palpable nodes in the cervical, supraclavicular, axillary or inguinal areas. j. Genital/rectal Her pubic hair is sparse. The labia is flattened, the vula is atrophied. She does not have palpable uterus, ovaries or masses. She has at least two (2) bowel movements a day; her bowel is mostly soft and brown, shows no mucus, blood or tarry stool. She has no rectal bleeding, and her stool’s color and consistency do not change. k. Neurological Melissa appears orientated to time, place, person and events. Her facial expression correlates with state of health – that is, she appears somewhat sad and anxious. Her speech is clear and coherent. She is able to provide lucid answers to medical questions. Her long-term memory and short-term memory are intact. Her cranial nerves (CN) I-XII are integrated. Summary of assessments The focus of this summary of assessment is the client’s complaint that she vomits excessively, she’s very weak and nauseated. A diagnosis of this – with the foregoing background information – would consist of an imbalanced nutrition, i.e., less than body requirements as evidenced by prolonged vomiting for a day, dry skin and frequency of micturition or fluid volume deficit. She may be told, as a matter of intervention, that her vomiting and frequent voiding are due to her diabetes that is out of control. Her feeling of being extremely weak is related to prolonged vomiting, probably dehydration and altered tissue perfusion (see Clouse and Lustman 2002, pp. 39-41). The diabetic patient should also be told the diagnosis about her numbing and paining legs. It is because of ineffective tissue perfusion, evidenced by flisk for infection related to darkened area on left great toe. She will be given instruction about footcare – e.g., washing feet in warm to cool water, drying feet thoroughly after each wash, using lotion lavishly and drying feet after application, and using gentle approach with feet, and the like (see NDIC 2009). References: Clouse, R.E. & Lustman, 2002. Case study: chronic vomiting in a patient with type 2 diabetes. Clinical Diabetes, 20 (1), pp. 39-41. Kulik, D. & Lee, D. (n.d.). Heart attack. MediciineNet.com. Available at: http://www.medicinenet.com/heart_attack/article.htm [Accessed 16 April 2010]. Marks, J. (n.d.). Gastroesophageal reflux disease (GERD, acid reflux, heartburn). MedicineNet.com. Available at: http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htm [Accessed 16 April 2010]. National Diabetes Information Clearinghouse (NDIC). 2009. Diabetic neuropathies: the nerve damage of diabetes. Available at: http://diabetes.niddk.nih.gov/DM/pubs/neuropathies/ [Accessed 16 April 2010]. National Lung Health Education Program (NLHEP). 2000. Frontline assessment of common pulmonary presentation: dyspnea. NLHEP.org. Available at: http://www.nlhep.org/books/pul_Pre/dyspnea.html [Accessed 16 April 2010]. Siklos, P. 1999. Clinical history and examination (including risk factors, epidemiology and aetiology). In P.M. Schofield, Angina Pectoris in Clinical Practice. London: Martin Dunitz, Ltd., pp. 1-18. Wolf, D. 1990. Evaluation of the size, shape and consistency of liver. Clinical Methods. Available at: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A3049 [Accessed 15 April 2010]. Read More