Physical Assesment Case Study # 2 - Research Paper Example

For instance; diabetes can be detected first through an eye examination (Lavine, 2001). Before admission of the patient, it is important to present a comprehensive document containing the history and exam findings of the patient. Additionally, a medical plan should be outlined in addressing the issue which led to hospital visit by the patient. In the document, the information should be arranged in a logical order. The data that has immediate relevant information about the patient’s conditions should be given priority.

This information is important to the medical service providers that are going to attend to this particular patient. Finally, this document is crucial for medical purposes (Blanco et al., 2002). Jessica, 32 years lady, has experienced a decrease of vision in her left eye. The condition started this morning and it has worsened progressively over the past few hours. In the past, a month ago, she had blurring of her vision. She has been experiencing some pain when trying to move her eye. When the eye is rested there is no such pain.

She also has problem of determining colors. The condition just came and it was not triggered by exposure to chemicals. The eyes do not show any sign of redness or tearing. In her argument, she thinks that past condition is related to the present condition. Additionally, she has observed that the problem might be related to overheating since the vision improved when she went to a cool air condition environment. She has always been physically healthy. It is only in her childhood that at 10 years she had chickenpox.

She also had tonsillectomy at age 11. She has never been hospitalized in the past. It has also been noted that her father had coronary artery disease and her mother suffered from hypertension. Currently she has no other medical problems. In the area of education and career; she is a trained mathematics teacher at undergraduate