Health history and assessment RUA PDF

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Health History and Physical Assessment RUA Nia M Ducre Chamberlain University

HEALTH HISTORY 2 My patient A.B. is a 44-year-old female. A.B. is currently a full-time patient registrar at a local hospital. Five years ago, the patient had one child through a caesarean section. The patient believes that she is healthy but admits that she does suffer with anxiety that stems from a car accident, and rheumatoid arthritis. A.B. tells me that her primary care physician prescribed her Zoloft to help manage her anxiety. Furthermore, A.B. does experience arthritis pain in the wrist and ankles. The patient states that cold weather and excessive movement makes the pain worse and the patient uses Voltaren cream to help relieve the pain. The patient describes the pain as pins and needles with a throbbing sensation, and sometimes the pain does travel from the wrist to the fingers. Even though the patient says the pain does come and go, the pain is at a seven out of ten when experienced. A.B. is Muslim and prefers a same sex physician due to religious reasons. A.B. does not smoke tobacco, drink, or use drugs. The patient does not have any allergies and is not experiencing any discomfort. The patient is a middle age adult who is currently suffering from a chronic health problem. This patient is in the generativity vs. stagnation psychosocial stage meaning that the patient is making use of time and having a concern with helping others and guiding the next generation. The patient’s maternal grandmother and mother both suffer from high blood pressure. Furthermore, her maternal grandmother also suffered with diabetes before dying in 2015 from congestive health failure. My patient informed me that her maternal grandfather died from lung cancer in 2018. Both the paternal grandparents suffer with rheumatoid arthritis. The patient’s paternal grandfather survived a stroke but does have paralysis on the left side of his body. Furthermore, A.B.’s paternal grandmother has had a heart attack, but she is doing better now. The patient’s family is very supportive and helps her get to and from appointment since she does not have transportation.

HEALTH HISTORY 3 A.B. has no changes or visible deformities in skin, eyes, ears, nose, mouth, or neck. Head is normocephalic without deformities and midline. Facial structures are symmetrical without any drooping. Sclera is white conjunctiva is pink and moist. The pupils are round, equal in size and reactive to light and accommodate bilaterally. Looking at the ears there are no signs of redness or discharge and cranial nerve eight is intact. Both nares are patent bilaterally with no signs of deformities, inflammation, or drainage. The uvula is midline, pink, and moist with no signs of redness of drainage present. Looking at the neck the patient is experiencing hypothyroidism but there is no swelling of the lymph chain. The patient’s respiratory rate is within normal limits and rhythm is regular. There is no pain, tenderness, or masses and the lung sounds are clear. The carotid pulses have a regular rate and rhythm, 2+ bilaterally. There are no signs of jugular vein distention and the heart rate is 82. The patient is alert and oriented x4. A.B. is in a pleasant mood with appropriate thoughts. The patient’s facial expressions are positive, and her speech is clear. All her cranial nerves are intact and muscle strength is 5 bilaterally for upper and lower extremities. The patient’s stomach has a flat contour and bowel sounds are normal in all four quadrants. There is no tenderness, pain or distention present. The patient has an even steady gait and is stable in the standing position independently. There are no signs of lordosis, kyphosis, or scoliosis when erect and patient has full range of motion. A.B shows no signs of edema and femoral, popliteal, posterior tibial, and dorsalis pedis pulses have a regular rate and rhythm, 2+ bilaterally. Based on the health history and physical examination findings two health education topics that I think would be beneficial for the patient are education on rheumatoid arthritis and grief consoling. Rheumatoid arthritis is a chronic inflammatory disorder affecting many joints, including those in the hands and feet. Rheumatoid arthritis is one of the most prevalent chronic

HEALTH HISTORY 4 inflammatory diseases. “The lower the disease activity achieved at 6 months, the better the longterm outcome; reaching stringent clinical remission within 3-6 months halts damage progression independent of the type of therapy used” (Smolen, 2016). The pain of grief can disrupt your physical health, making it difficult to sleep, eat, or even think straight. Attempts to suppress or deny grief are just as likely to prolong the process, while also demanding additional emotional effort. In 1969, Elisabeth Kubler-Ross identified five stages of grief: denial, anger, bargaining, depression, acceptance. “Each individual may experience a different set of specific emotions, but, in general, these emotions diminish as time passes and with support from family and friends” (Ringold, 2005). During my interaction with the patient we sat down in her home to discuss her health history. I chose my patient’s home because I wanted a quiet environment that was free from any distractions. We met at around noon and I explained the importance of completing the health history and what the result may indicate. During my interview, I made sure my patient was comfortable and that I maintained eye contact, so A.B. would know that I valued her time and participation. This interaction compared to what I have learned because I had to use the therapeutic communication techniques when asking questions. Although, my overall interview was a positive experience there were some communication barriers. First, when discussing the patient’s family history, A.B began to get emotional when we spoke about family members that are deceased. I reassured A.B. that if she needed to, we could take a break and regroup. In the future, I would like to help my patient by educating them with tips to help with grief and coping with death. Furthermore, a pamphlet on grieving or information on healthy grieving techniques is something that I wish I had available to provide to my patient in that moment.

HEALTH HISTORY 5 Somethings that went well during the assignment were utilizing my therapeutic communication skills, being able to effectively empathize with my patient, and successfully interviewing and documenting my patient’s responses. There was only one unanticipated challenge during the assessment, and it was my getting emotional while I was inquiring about a relative that perished. Following this event, I comforted C.W and let her know that grief is a normal emotion and that she may benefit from speaking with a grief counselor. Next time, I will alter my approach by not just jumping directly into the activity but allowing my patient to get comfortable with general questions to prevent awkwardness. Also, I will allow more time in between question and response, so the patient does not feel rushed and has time to analyze the questions thoroughly. Also, I had to be mindful to use open ended questions to obtain as much useful information as I could.

HEALTH HISTORY 6 Reference:

Ringold, L. (2005, June 1). Grief. Retrieved April 17, 2021, from https://jamanetworkcom.chamberlainuniversity.idm.oclc.org/journals/jama/fullarticle/200999?resultClick=1 Smolen, A. (2016, October 22). Rheumatoid arthritis. Retrieved April 17, 2021, from https://search-proquest-com.chamberlainuniversity.idm.oclc.org/docview/1833938124? accountid=147674...