Example Of Essay On The Health History And Physical Examination
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According to Smith, Duell and Martin (2012), the subjective data or health history should be initiated with biographic information that must include age, gender, education, marital status and living arrangements.
Therefore, the history taken starts from the demographic data which can be seen as following:
Referral Source: ER
Marital Status: Married
History of Presenting Complaint (HOPC):
According to the patient she was in usual state of health one week ago when she developed chest pain. The PQRST of pain is as follows:
Quality: Dull aching
Region and radiation: Left para-sternal area radiating up to her neck
Severity: Mild to moderate
The pain started after 45 minutes of exertion and it was associated with shortness of breath but there was no sweating, vomiting or nausea. The pain subsided on resting in a cooler environment.
She experienced two more similar episodes and they had same attributes and symptoms. She developed chest pain three days ago that lasted 15 minutes and it occurred while she was walking her dog. It was also relieved on resting. This evening she again experienced an episode lasting for 30 minutes which compelled her to wake up from her sleep and she presented to the ER. She did not take or do anything regarding her pain besides taking rest. She confirms that she did not feel dizziness, palpitations, exertional dyspnea, orthopnea or paroxysmal nocturnal dyspnea besides experiencing shortness of breath during these attacks. The pain did not exaggerate on movements and was not associated with food ingestion, palpable pain and she never had symptoms pertinent to gastroesophageal reflux disease (GERD). Prior to this, she never experienced any such pains or claudication and is not diagnosed with any heart problems. Although, she is a known case of hypertension diagnosed 3 years ago.
She has no smoking history or any other co-morbids. She had a total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) 6 years ago but denies taking hormone replacement therapy. Her family history is positive for premature coronary artery disease (CAD) and is unaware of her cholesterol levels.
Past Medical and Surgical History:
2004: Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) for uterine fibroids.
2012: Hypertension was diagnosed and she was started on an unknown medication which she stopped 6 months later owing to its effect of causing drowsiness.
2013: Developed peptic ulcer disease which was resolved after she was prescribed cimetidine. She denies history of cancer, prior heart diseases or any pulmonary disease.
She is allergic to Penicillin and got to know in 1985 when she developed hives.
Alcohol: She takes 1 to 3 beers every weekend and 1 glass wine once a week.
Tobacco use: None
Medications: No prescription or illegitimate medicinal use. She takes over-the-counter Ibuprofen for headaches.
Mother: she is 82 years old, alive and well.
Father: Died at the age of 55 due to heart attack. He had no siblings and family history is positive for hypertension but not cancer or diabetes.
Patient is generally well and takes care of her mother who is living with her. She has two sons and one daughter. One of the sons died serving in the army and the other one has a small shop near a gas station. She mostly relies on the pension she gets each month. Her daughter is married and settled in a different state. Her financial needs are hardly fulfilled mainly due to the meagre amount of pension she receives and her son can’t support her too well. While asking about financial situation, she sounded really depressed and sad.
HEENT: She does not complain of headaches, altered vision, ear or nose problem or throat problems like sore throat.
Cardiovascular: Mentioned in history of presenting illness
Gastrointestinal: There is no history of dysphagia, vomiting, nausea, altered bowel habits. She has epigastric pain which is burning in quality and occurs at least twice a month particularly aggravating at night.
Genitourinary: No history of dysuria, polyuria, vaginal bleeding, hematuria or nocturia.
Musculoskeletal: She has pain in lower back region which is aching in quality which occurs at least once a week after she is done doing gardening. It normally subsides by taking Tylenol. Otherwise, there is no history of myalgia, pain or muscular aches.
Neurological: She denies numbness, weakness or incoordination.
Blood pressure: 168/100 mm Hg
Pulse: 90 beats/ minute
Respiratory rate: 20 breaths/ minute
Her skin has normal texture, appearance and temperature.
Scalp is normal
Pupils appear rounded symmetrically to about 4 mm. They are reactive to light and accommodation. Sclera and conjunctiva appears normal. On fundoscopic examination, normal vasculature without haemorrhage was seen.
Examination of tympanic membrane and external auditory canal is unremarkable.
Nasal cavity and mucosa both appears normal.
Oropharynx also appears normal without erythematous mucosa or exudates. Tongue and gums are also normal.
Mobility of the neck is normal in all ranges without abnormal cervival lymphadenopathy or supraclavicular palpable lymph nodes. Trachea is in midline with normally appearing thyroid. No carotid bruits were heard. Jugular venous pressure (JVP) was measured and came out to be 8 cm with patient lying at 45 degrees.
On auscultation, basal crackles were heard in both lung fields. The point of maximal impact (PMI) is in 5th intercostal space at mid-clavicular line. At right 2nd intercostal space, a grade 2/6 systolic murmur is heard which radiates towards the neck. 3rd heart sound is audible at the apex without presence of 4th added sound.
Breast examination showed cystic changes bilaterally but otherwise the examination was insignificant.
Symmetrical in shape, not distended, umbilicus placed centrally and inverted. Normally audible bowel sounds in all areas except audible bruit in the left para-umbilical area. No mass or visceromegaly was observed and liver span was calculated as to be 8 cm by means of percussion.
Examination showed absence of cyanosis, clubbing, and edema. All peripheral pulses were normal without any delay.
Lymph nodes were impalpable in supraclavicular, inguinal, cervical or axillary regions.
Normal sphincteric tone of the rectum was observed without any mass or tenderness. Stool is brown on gross appearance with negative fecal occult blood test.
On pelvic examination, external genitalia appeared normal with normally appearing vagina and cervix when examined using speculum. On bimanual examination, uterus, ovaries or any other mass were impalpable.
Cranial nerves II till XII are normally functioning. Motor and sensory component of the limbs were unremarkable. Gait and higher cerebellar functions were all normal. Reflexes are normal and present symmetrically in both extremities.
Two major health education problems that are evident in this case is poor patient compliance and finance associated depression.
She has a mother to take care within the limited amount of pension she gets every month from the government. Her son is not very well established with a death of young son in the war and early demise of his spouse. All these factors could point to depression which was evident when she was interviewed. Fiske, Wetherell and Gatz (2009) described financial constraints as one of the main factors that leads to depression in old patients.
Similarly, Mrs. DePaul taking her medicines on time that were prescribed to her to address her high blood pressure. She is unaware of the grave consequences of persistent high blood pressure specially when her father died of coronary artery disease. Her lack of compliance could be due to the cost involved and the lack of awareness both in this situation. Jin, Sklar, Oh and Li (2008) described the various factors that leads to poor patient compliance. They stated that lack of awareness and financial constraints or cost and affordability issue are two of the most common factors that leads to poor patient outcomes. This poor compliance ultimately leads to higher mortality and morbidity and is associated with poor prognosis.
Although, she was a bit reluctant initially but I won her confidence by being compassionate and not too overwhelming. I listened to her completely and patiently, giving her ample time to express herself.
During physical examination, she was very depressed because she was reminded of her deceased son and had to discuss her poor financial status. I had to counsel her regarding the availability of help and various support sessions in her vicinity that might help her cope with it. Fortunately, she was very cooperative and therefore let me do the examination in detail.
I had all the information required regarding Mrs. DePaul and that gave me the edge to win her confidence.
Fiske, A., Wetherell, J. L., & Gatz, M. (2009). Depression in Older Adults.Annual Review of Clinical Psychology, 5, 363–389. doi:10.1146/annurev.clinpsy.032408.153621
Jin, J., Sklar, G. E., Min Sen Oh, V., & Chuen Li, S. (2008). Factors affecting therapeutic compliance: A review from the patient’s perspective. Therapeutics and Clinical Risk Management, 4(1), 269–286.
Smith, S., Duell, D., & Martin, B. (2012). Chapter 11; Physical Assessment. In Clinical Nursing Skills: Basic to Advanced Skills (8th ed., p. 283). Boston: Pearson.
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