Sample Nursing Paper on Individual Client Health History and Examination

Individual Client Health History and Examination

Introduction

The disease landscape including prevalence, severity and type of diseases have changed significantly in the world today. This also calls for innovative and different approaches in the treatment, management and prevention of these diseases. Various diseases and infections need different medication approaches and standards since they exhibit different magnitudes, according to the varying immune systems among patients (Braunwald & Baughman, 2001). Therefore, it is imperative that different patients, even if suffering from similar diseases and infections, are given special attention and recommended for the best medication depending on the diagnosis of their problem. During the medical inquiry and assessment process by doctors, it is relevant that the particular patient’s health history be performed so as have the right procedure for undertaking medication. This essay is a health assessment of an adult and aims at coming up with a direct care experience.

1. Health History

I have performed a healthy history with an old adult, by filling his responses on the health history form. Available information includes details of Mr. Smith’s personal information, medical information dental information and other relevant demographic data. The patient had a recent weight loss; he has been feeling headaches and has difficulty in swallowing. For the last two years, he had chest pains, food intolerance, some mild problems, at the time experienced loss of feeling, tolerance of temperature and has been exposed to radiation.

2. Physical Examination

Under physical examination, I have conducted an assessment of the Cardiovascular and Lymphatic Systems (CLS). The client has been diagnosed with vascular problems and has swollen glands. He is a smoker who takes an average of four cigarettes a day. He takes drinks with caffeine, alcoholic beverages, and bulge veins in his legs, and swelling feet making the shoes feel tight.

He felt tired and have some sensations such as pain and burning in his legs. He has rough skin with rashes all over and sweats at short time intervals. Tests on his eyes reveal normal vision and visual acuity. Palpating the skull and examining the neck, as well as the lymph nodes, things were normal, except the skin rashes all over.

3. Documentation of the Findings of the Physical Examination

Situation

The situation here is that Mr. Smith has swollen glands. He I having bulge veins in his legs and his feet are growing making his shoes feel tight. He feels tired and complains of pain and a burning sensation on his legs. His skin is full of rashes all over, and he sweats a lot at short time intervals. He has difficulties in swallowing food due to pain.

Background

The background information that fully validates his condition is the knee replacement that he had for two weeks ago. He got an accident while cycling on his motorbike and had severe injuries in his feet that have developed to internal problems leading to the swelling of the feet. He said that he had traveled to see a relative three weeks and took a meal with some of the foods that he is allergic to.

Three hours earlier, he started complaining of chest problem and discomfort. His pulse rate was 120. Results from his blood pressure indicated 128 over 54. All over the time, he has been restless, and when taking a close observation, I realized he is short of breath.

 

Assessment

After taking a keen assessment of his situation, it is evident that he may be having problems and complications from cardiac muscles as well as a pulmonary embolism. He complains of his pain getting worse today as compared to the other previous days, and also a pain when he tries to swallow food. Upon undertaking further medical observations, his temperature has returns to normal, and his incision sites are good. His has elevated levels of blood pressure, together with heart pumping rate as well as respirations.

The patient recently lost weight and experienced headache and throat pain leading to difficulty in swallowing. For the last two years, he had chest pains, food intolerance, some mild problems, at the time experienced loss of feeling, tolerance of temperature and has been exposed to radiation

Recommendation

I recommend he should be examined by a dcotor immediately. He should start using O₂ immediately.

4. Physical Examination Worksheet

Physical Examination
This section has been completed by a medical practitioner upon verification of Mr. Smith’s health condition.
Height (inches): 5.7			Weight (KGS): 72		Body Mass Index (BMI): 24.98					Gender: Male
Pulse Resting: 120			Initial Blood Pressure: 128/54		Repeat Blood Pressure: 128/54
Physical Examination
#	Normal	Abnormal		System or Organ		#	Normal	Abnormal	System or Organ
1.	ü			Head, Face, Neck, Scalp		10.		ü	Skin
2.	ü			Eyes ( Pupils and EOM)		11.			Lymphatic
3.		ü		Mouth And Throat		12.	ü		Neurology
4.	ü			Ears / Drums		13.		ü	Vascular System
5.		ü		Lungs and Chest		14.	ü		Genital-Urinary System
6.		ü		Heart		15.	ü		Hernia
7.	ü			Abdomen		16.	ü		Missing extremities / Digits
8.	ü			Upper / Lower Extremities		17.		ü	General / Systematic
9.	ü			Spine / Musculoskeletal

 

Comments on the numbered abnormal systems/organs

Chest- Mr. Smith has been complaining of chest problem which totally made him uncomfortable during the medical physical assessment period. Lungs- I have observed a number of breathing problems in him. Breathing problems are always associated with lungs malfunctioning.

Throat- he has difficult in swallowing, especially solid foods. When he tries to swallow solid or rather chewed food particles, he feels a lot of pain.

Heart- His heart pumping is above the normal, reaching 120. A normal heart pumping for a healthy human being should range between 60-100 bpm (Braunwald & Baughman, 2001).

Skin-his skin is full of rushes.

General/Systematic- the general functioning of the body has been hindered by the complications he is having with breathing problems, chest pains, skin and rushes and increased heartbeats.

 

5. Physical Examination Findings Summary with Interventions

Mr. Smith, aged 58, has had a recent weight loss and has difficulty in swallowing food. If Mr. Smith had taken aspirin or acetaminophen before, for the purpose of relieving the headaches, a different medication approach should be taken. Further medical analysis and tests should be made to identify if the headache is a symptom of a different condition.  Since the headache is severe, he should be given migraine treatment (Kernick & Goadsby, 2009). If it’s chronic, then the underlying disease should be treated to end the chronic daily headaches.

For the case of the swallowing problem, Mr. Smith should given medicines aimed at relaxing the esophagus muscles and get injected with botulinum toxin. If the symptoms persist, the cause of the dysphagia should further be looked into through endoscopy, X-rays and various tests esophageal acid (Reichel & Arenson, 2009). At times, a rapid heart rate may normalize itself, bit if the symptom or rather the condition persist, he should be given an injection to restore the heart rate. This will be an anti-arrhythmic medication with an aim of restoring the normal heart rate (Rippe, 2015).

The rushes in his screen arose as a result of the food that he took yet he has an allergy to. For the purposes of clearing the rushes, he should be given a short course of oral steroids and stop from eating the particular food he ate.  If all these medical interventions are put in place, then with no doubt, Mr. Smith will recover from his conditions.

 

 

 

 

References

Braunwald, E. & Baughman, K. (2001). Essential atlas of heart diseases. New York: McGraw-Hill.

Kernick, D. & Goadsby, P. (2009). Headache. Oxford: Oxford University Press.

Reichel, W. & Arenson, C. (2009). Reichel’s care of the elderly. Cambridge: Cambridge University Press.

Rippe, J. (2015). Preventing and Reversing Heart Disease For Dummies. Hoboken, NJ: Wiley.