Comprehensive Health History and Physical Examination - Essay Example

?Comprehensive Health History and Physical Examination of Patient Andrew Brown 10 October ChiefComplaint Mr. Andrew is a pleasant 47 year old man. He is complaining of a having chest pains continuously for the past three days. History of Present Illness Mr. Andrew is yet to seek medical attention as concerns the chest pains which he say began three days ago. Andrew says that he has been enjoying his good health and working normally at work until three days ago when the chest pains began. It was around six in the evening while he was driving from work when he noticed a change in his body. There was an abrupt pain onset of the pain to his right side which occurred for a small period of time about one to two minutes. He thought that he might have strained while driving and this might have resulted in the pain. The pain slowly moved from the parasternal area towards his neck. This was the first time he experienced such pain and describes his day as a normal day at the office with no strains. He felt tired at this time as the pain continued to radiate upwards. The pain subsided a little when he got home but he felt a discomfort that was accompanied by a shortness of breath. At this time, he was not nauseated or sweating. The pain seemed to disappear immediately he arrived home and rested. Two days ago the pain returned again and this time a little severe than the first episode and lasted close to five minutes. The pain seemed to emanate from the same place as the previous episode. He experienced this twice during the day in the morning and in the evening. In both instances he was not strained but simply walking around in the office. He went home and took a rest again and the pain seemed to disappear completely until today when the pain episode manifested. All this time he was contemplating of seeking medical attention but did not. He never used any pain relievers or any other drug that could ease the pain. The reason for this he says is that the pain seemed to last for a short period of time and would disappear itself or would end immediately he went to rest. This made him think that the pain was as a result of work. The patient says that he did not experience any other symptom apart from the shortness of breath during the pain episodes. There was no dizziness or palpitations. He also says that there was no other exertional dyspnea, orthopnea or paroxysmal nocturnal dyspnea. Interestingly the pain did not alter during movements or during food intake. There was also no palpable pain. He has never been informed of having heart problems. He has never had a problem with his chest before and neither has he ever experienced chest pains in his life. He does not have claudication. However, Andrew was diagnosed with hypertension about 2 years ago. Andrew is not a smoker and has no symptoms of diabetes. He was only diagnosed with the hypertension 2 years ago which he is fully aware of and had a total abdominal hysterectomy and a BSO about a year ago. Andrew has not been on any hormone replacement therapy of late. He also says that their family has a history of premature CAD. He has been monitoring his cholesterol level for quite some time but at present he does not know. Past Medical, Surgical, and Social History Surgical- has no history of surgical operations Medical history Childhood: diagnosed with mumps at the age of 7. No measles, croup, pertussis, rheumatic fever, scarlet or polio. Accidents: Andrew had an accident while at the age of 12 while riding his bicycle. He developed a fracture. At the age of 25 he was involved in a car accident although he survived with bruises. Chronic illnesses: In 2010 he was diagnosed with hypertension and was on medication until last year when he stopped taking the medication due to the drowsy effect they were having on him. In 2008 he was diagnosed with peptic ulcer disease which was successfully treated after three months using cimetidine. Hospitalizations: He was hospitalized at the age of 12 after the accident where he developed a leg fracture. He underwent therapy and the fracture successfully healed after 2 months. At 27 he was hospitalized with typhoid after his visit to Africa. This was successfully resolved after 3 weeks using ciprofloxacin. Immunizations: Underwent all childhood immunizations, last TB test negative in 2011. Last examination: No physical examination has been performed for the past five years. Little history of previous chronic conditions requiring attention. Allergies: allergic to eggs, allergic to medications with sulphur. Not allergic to the environment. Current medication: The patient is on medication at the moment taking paracetamol 1 gm. 3 times daily for the pain and Diclofenac 100mg a day for his aching back. Social History At 47, Andrew is a widower, wife passed away in a car accident five years ago. He has two children, his son is 20 and his daughter is 13. He lives with both of them in the same house. Andrew is an active participant in community and local events. His hobbies are swimming and watching movies which he does during weekends and mostly after work. He is a marketing manager and his job involves travelling around the country. He does not get time for physical activity but prefers to jog once in a while during weekends. He is currently seeing another lady at the workplace, a relationship that his son is against. He does not smoke but is a social drinker and loves to buy a bottle of red wine to the house occasionally. Family History Andrew is the second born in a family of three, 2 boys and one girl. The parents were married until his father died of stroke in 2000. His father had a history of diabetes and generalized anxiety. This is present in the family with all the 3 experiencing these symptoms although on a minor basis. He still has his mother who is 74, suffering from type II diabetes. She has a history of fibroids and breast cancer. The family history is marked with hypertension, diabetes and cancer. His grandfather died of stroke and had a history of lung cancer while his grandmother died of type II diabetes. List of Risk Factors There are a number of risks factors which are based on the patient’s health history over the years. The risk of hypertension and type II diabetes are inherent due to the sedimentary life style. From his family’s health history, the patient is at risk of cancer, cardiovascular diseases such as stroke and hypertension. These risks are modifiable with a proper diet and a continuous involvement in physical exercises to avoid the development of these conditions. Proper diet and exercise are the only way that these risks can be mitigated. The history of anxiety in the family presents the risk of depression and other metal conditions. This is modifiable through appropriate medication as well as therapy to help prevent the development of the conditions. From the family’s health history, cancer is a cause for worry and this also puts the patient at risk. It is thus non modifiable but proper routine checkup could help prevent the onset of such a condition. Review of Systems Skin: No rashes or other changes witnessed Hair: Grey hair seen which is normal for his age Nails: In good condition, no abnormalities noted Head: no frequent headaches, no head injuries now or in the past, no dizziness. Neck: No lumps, goiter, pain. No swollen glands witnessed Ears: Hearing is good, no tinnitus and vertigo. No ear infections Eyes: Reading glasses for 3 years, last checkup a year ago. Vision is clear. Nose: No nasal problems or infections witnessed Respiratory: Shortness of breath witnessed in the past three days, complains of chest pains. No coughing. A non-smoker. The pain can be rated as 4/10 though it varies highest at 7/10. Sometimes the pain very painful and makes him uncomfortable. Musculoskeletal: He complains of lower back pains, the aching is not severe. He rates it at 2/10. It happens especially after hard work around the house and at work. The pain is relieved with Tylenol and Diclofenac at times. The patient has no history of arthritis, however he had a fracture due to an accident he was involved in which was successfully resolved. He is comfortable with a full range of movements and has no problem with motion. Peripheral vascular: No history of varicose veins, no swollen ankles, no history of phlebitis or leg pain (Jarvis, 2011). Neurologic: No complains of weaknesses, numbness or incoordination are made Endocrine: No known thyroid trouble, temperature intolerance, sweating average. A family history of diabetes puts his at the risk of the condition. Functional Assessment & Nutritional Assessment Self-concept: He is working on getting a master’s degree in marketing and management. He talks well of his job as enjoyable. He views himself as honest, hardworking and trustworthy. His self-esteem is quite high and he feels that he has accomplished much in a short while although his wife’s death is still weighing heavy on him. He is getting counseling to resolve this. Activity/exercise: He rarely engages in physical activity except for intentional walking around the office or during field work. He goes for a morning jog occasionally on weekends. Sleep/rest: He gets adequate sleep and sleeps close to eight hours every day. No signs of insomnia. He rests on weekends and after work mostly. Rarely goes on vacation. Nutrition: The patient eats a balanced diet each and every day. The daughter prepares the meals most of the time with him. Most of their meals are made at home. He does the shopping with his daughter most of the time. Interpersonal relationships: He has been moving from place to place due to the nature of his job. He does not have many friends due to this. He is quite social and has many friends at the workplace where he is liked and valued by many. He has a good relationship with his children and his mother who is far away and whom he is missing so much. Physical Examination Perception of health: Andrew views himself as having been having been in good health. His weight at 70 is good enough for his age. There is virtually nothing that limits his abilities and thus he performs activities as well as task more effectively. He likes swimming and watching movies something which he does with his children. He hopes to improve his health condition through exercises and medication. Vital signs: Ht (without shoes) 157 cm (5?9?). Wt (dressed) 70 kg. BMI 26. BP 164/98 right arm, supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6°F (Weber & Kelley, 2009). Mouth: Oral mucosa pink and moist. The tongue is symmetrical. He has two missing teeth. The oral hygiene is good. Throat: That throat is okay, no swellings or abnormal changes witnessed: oral pharynx is normal without erythema. Sinuses: Mucosa pink, septum midline, no sinus tenderness Thorax, lungs: Lungs are clear to auscultation and percussion bilaterally. The patient needs a detailed cardiac examination except for crackles heard in the lung bases bilaterally. PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. Heart: Heart rate (HR) 88 and regular. Neck vessels: Neck supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt. Abdomen: The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right paraumbilical area. No masses or splenomegaly are noted; liver span is 8 cm by percussion Mental status: Mental state normal, no anxiety, no depression Extremities: No cyanosis, clubbing, or edema are noted. Peripheral pulses in the femoral, popliteal, anterior tibial, dorsalis pedis, brachial, and radial areas are normal Musculoskeletal: full range of motion witnessed, no abnormalities witnessed in motion or movement from leg to neck Neurological: Cranial nerves II-XII are normal. Motor and sensory examination of the upper and lower extremities is normal. Gait and cerebellar function are also normal. Reflexes are normal and symmetrical bilaterally in both extremities. Conclusion Including List of Normal and Abnormal Findings, and Plan with Recommendations According to the patient’s full description and family health history, the following are some of the possible diagnosis: chest pains with a range of symptoms of angina pectoris. Due to the nature of the pain which seems to be in constant change, it easily fits the unstable angina and the patient may need hospitalization. There is also a possible recent onset of hypertension and abdominal bruit and this is in line with family history and from physical examination where there is a lack of hypertensive retinopathy and left ventricular hypertrophy. The Plan with recommendations 1. The patient should be monitored carefully for any changes in the intensity of pain which might indicate an impending myocardial infarction. 2. The patient should be placed on platelet inhibitors such as Aspirin to help decrease the risk of myocardial infarction. Nitrates should also be started in order to reduce the pain and to eliminate the risk of occlusion 3. It is necessary that the patient’s level of cholesterol is continuously monitored as soon as they are discharged. The patient should also be put on a physical exercise program. References Jarvis, C. (2011). Physical examination and Health Assessment (6th ed.). London: Elservier Health Sciences. Weber, J. R., & Kelley, J. (2009). Health Assessment in Nursing (4th ed.). New York: Lippincott Williams & Wilkins. Read More