Health Assessment II: Case Study of a 20-year-old Asian Female Patient, Lecture notes of Financial Accounting

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NR304 Health Assessment II Chamberlain University College of Nursing NR304- Health Assessment II Health History: Subjective Data Demographics

My patient is a 20yr old female of Asian descent, she lives Houston with her parents and four other siblings. Reason for Care Patient has come in for a physical exam, a head to toe assessment. Present Illness No present illness according to the patient. Perception of Health The patient feels healthy overall, but she’s here to get her one year check up to make sure all is well. Past Medical History Patient is up to date with all immunization, she has had no hospitalizations, surgeries or blood transfusion. Patient’s only diagnosis is iron deficiency anemia, which she is taking iron supplements once a day for. Patient’s onset of menstruation began at the age of twelve years old, which she states is irregular and painful a times. Patient’s last menstruation was Aug 13, 2020. Family Medical History Patient’s father is fifty-six yrs. old and does have significant health problems, he has had a stroke three times, he has hypertension, diabetes and high cholesterol. Patient’s mother is forty-six years old and also has high blood pressure. Patient also has 4 older siblings with no significant health problems. Patient’s maternal grandparents are still living, grandmother has high blood pressure and grandfather has history of hernia. Paternal grandmother has diabetes and high blood

pressure, and paternal grandfather has passed. Patient is not married, nor does she have any children of her own. Review of Systems Patient has not had any significant symptoms or changes to her body from head to chest. She does not use any prescribed drugs, inhalers, or any over-the-counter drugs, apart from iron supplements for her anemia. Patient has no allergies to medication, latex, or iodine/betadine. Developmental Consideration Patient states she works out regularly at least four times a week for thirty minutes, she does not diet and ranks her salt and fat intake as medium. She also drinks at least two cup of tea a day. Patient does not drink, use tobacco or use any recreational or street drugs and not sexually active. Patient lives with her family, where she feels safe and secure of her overall well-being. Cultural Considerations Patient and her family are Indian, and many cultural traditions are incorporated into their everyday lives, such as cooking Indian food and spending time in many family gatherings listening to native music when possible. Psychosocial Considerations Patient has no major mental health problems and has never had a need to seek professional help. Collaborative Resources

Most of the resources for this RUA paper came from the patient herself, to also include the course textbook, Physical Examination and Health Assessment. 8th^ edition. Physical Examination: Objective Data (HEENT) Head, Eyes, Ears, Nose, and Throat Patient has two eyes, one nose, one mouth and two ears. All facial structures are symmetrically placed on patient’s head. In palpatingthe head, I did not see or feel any lesions, no masses of infestations are noted. Looking at the patient throat area, there are no masses or lesions noted on trachea area and trachea is midline. Upon inspection of the eyesand face there are no discharge, redness or lesions. There are no infestations to your eyebrows, eyelids, or eye lashes. Pulling down at the bottom of the eyes, conjunctiva is pink, and sclera is white. Next test forPERRLA, I ask patient to look straight ahead and shine my penlight in her eye, her eyes are direct, consensual, direct consensual. I asked patient to focus on that red dot on the wall behind me.I say “now” look at the tip of my penand ask her to follow my pen my from left to right. Convergence is noted and PERRLA is also intact and noted. Everything looks good. Upon inspection of both left and right ears I see no lesions, no piercings or any discharge or swelling or redness. When inspecting the ears, same thing when shining the light in your ear I do not see any discharge, swelling or redness.Now for your voice test I have the patient please sit with her back towards me cover one ear, I am going to whisper a word and she repeats it back to me. Now the other ear, both words are correct, so voice test is normal, so normal hearing is noted. So now for your nose please look up at me for just a min.Upon inspection of the external structure I do not see any lesions.The nose is symmetrically placed on the face and is midline, there is no deformities. Asking the patient to look up, shine my light I do not see any deformities, inflammation, no asymmetry and no

drainage. Next for bilateral patency. Icover one nares and ask the patient to breathe in and out. Bilateral patency of both nares is noted. Respiratory System Upon inspection of the patient’s chest I see no accessory muscles in use, looking at patient’s back and front together I see no scoliosis, kyphosis, or lordosis. AP diameter is less than transverse. Inauscultating the anterior and posterior lungspatientis asked to breathe in and out every timeshe feels my stethoscope. Starting right Upper lobe, left upper lobe, left upper lobe, right upper lobe, right middle lobe, left upper lobe, left lower lobe, right lower lobe.Lung sounds clear to lung sounds bilaterally in the anterior side. Now to auscultating the back, left upper lobe, right upper lobe, right lower lobe, left lower lobe, left lower lobe, right lower lobe. Lung sounds are clear to auscultation bilaterally in the posterior region of your lungs. Cardiovascular System First, I palpate the carotid pulse one at a time, they are two pulse and equal bilaterally. I then take my stethoscope and switch to bell side and auscultate your carotid pulse, there are no bruits noted. Next, I have patient sit in a 45-degree angle and shine my light in the right side of the neck and look for jugular vein distension no JVD noted. Last, I will look at the heart signs, doing this twice. Once with my bell side the other with the diaphragm. The right 2nd^ intercostal space aortic valve S2 greater than S1, left 2nd^ intercostal space pulmonic valve S2 greater than S1, left 3 rd^ Intercostal space ERBS point S2 is equal S1, Left 4th^ intercostal space tricuspid valve close to the sternal border S1 greater thanS2. Then left 5th^ intercostal space medial to the midclavicular mitralvalve S1 greater than S2. Then once more with the bell side, aortic valve s2 greater S1, pulmonic valve S2 greater than S1, erbs point S2 is equal to S1, tricuspid valve S1 less than S2,

mitral valve S1 greater thanS2. I then palpate the patient’s right and left radial pulse for 30 seconds, both are two plus and equal bilaterally. Neurological System Inspecting the patient, there are no unusually frequent or severe headaches; no head injury, dizziness or vertigo, seizures, or tremors. No weakness, numbness or tingling, or difficulty swallowing or speaking. Patient has no history of stroke, spinal cord injury, meningitis. Appearance, behavior, and speech appropriate; alert and oriented to person, place, and time; recent and remote memory intact. Cranial nerves: II: Vision 20/20 left eye, 20/20 right eye; peripheral fields intact by confrontation; fundi normal. III, IV, VI: EOMs intact, no ptosis or nystagmus; pupils equal, round, react to light and accommodation (PERRLA). V: Sensation intact and equal bilaterally; jaw strength equal bilaterally. VII: Facial muscles intact and symmetric. VIII: Hearing—whispered words heard bilaterally. IX, X: Swallowing intact, uvula rises in midline on phonation. XI: Shoulder shrug, head movement intact and equal bilaterally. XII: Tongue protrudes midline, no tremors. Motor: No atrophy, weakness, or tremors. Rapid alternating movements—finger-to-nose smoothly intact. Gait smooth and coordinated, able to tandem walk, negative Romberg. Sensory: Sharp and dull, light touch, vibration intact. Stereognosis—able to identify key. Reflexes: No Babinski sign, DTRs 2+ and = bilaterally with down going toes. Gastrointestinal System I asked patient if she was experiencing any nausea, vomiting, diarrhea, constipation or problems with urination. Inspect contour of abdomen, abdomen is flat and equal bilaterally. Auscultate bowel sounds in all 4 quadrants with the diaphragm Bowl sounds are present in all 4 quadrants. I press on patient’s stomach a bit, there’s no tenderness or pain. Palpate abdomen lightly in a

circular motion with fingertips, hitting all 4 quadrants No tenderness or rigidity noted with light palpation. Palpate abdomen deeply with one hand on the other, hitting all 4 quadrants No tenderness, organomegaly or masses noted with deep palpations. Musculoskeletal System Flexion I ask the patient to bending limb at joint and for extension straightening limb at joint. Abduction moving limb away from midline of body. The rotator cuff:Group of four (SITS) muscles and tendons support and stabilize shoulder. Range of motion (ROM) I ask for active voluntary ROM while stabilizing the body area proximal to that being moved. Kyphosis, Lordosis, screened for scoliosis with forward bend test.Expect straight vertical spine while standing and while bending forward; posterior ribs is symmetric, with equal elevation of shoulders, scapulae, and iliac crests no abnormalities notes. Peripheral Vascular System Inspection of upper and lower extremities for muscle waste, upper and lower extremities appear to be without muscle wasting. Patient grasp fingers with both hands, patient push feet against my hands Grip strength and foot pushes are 5/5 bilaterally. No weakness or tremors noted. Inspect lower leg and foot for edema No pretibial or pedal edema is noted. Palpate dorsalis pedis pulse, Dorsalis pedis pulse has a two plus regular rate and rhythm bilaterally. Movement and sensation of toes are intact bilaterally. Toes are pink and warm to touch bilaterally. Assess calves, and calves are without erythema, edema or heat NeedsAssessment

Two health education needs for this patient would be to continue to adhere to a healthy lifestyle, using running or other exercises to keep up with an overall good wellness. Running can be a therapeutic tool for different negative psychological conditions, such asdepression, anxiety, tension, mood changes, low self-esteemetc.(Markotiü, 2020, p. 234).The second would be to maintain a healthy diet and keep away from junk food.The optimum diet should be based on a varied food, as much fresh food as you are able to eat, mostly unprocessed food, and plenty of fruits and veggies.It is good to communicate in a culturally sensitive manner using language that is understandable to the patient. Assess patient/family learning characteristics (e.g., readiness to learn, preferred learning style, learning priorities, learning needs and desires, and learning barriers), knowledge deficits, and anxiety about the implementation of teaching methods; provide emotional support and additional information, as appropriate. interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence and assist, the effectiveness of the proposed health education, as those around the patient will start to notice healthy changes both physically and mentally about the patient. The individual is young; this is beneficial for the patient as she can align with her peers who also want to maintain healthy lifestyles, online resources and some social media outlets have of resources at the patient’s disposal for either quick easy recipes or at home exercises that do not require any financial obligations. Reflection

Due to the recent Corona virus pandemic I couldn’t meet with the patient physically, so this health history was conducted over the phone, in a quiet environment. I started from the beginning of assessment asking her questions and allowed her to give me the information as she was comfortable doing so. There were not many distractions while on the phone, except occasional phone connection issues. There were no unanticipated challenges during the assignment, both the patient and I were able to communicate with each other more clearly. To approach this next time, I would prefer to be able to physically meet with the patient for a more personable style of communication for the assignment. Overall, I felt there was a healthy and professional relationship established from the get-go, I was able to help the patient feel more at ease in her situation and encouraged her as she participated in the questionnaire. I believe, a healthy patient and healthcare professional relationship is built on trust and respect and it goes a long way in improving a patient's overall health. Reference

Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. Elsevier. Understanding the therapeutic nurse-patient relationship. CNO. (2020). http://www.cno.org/en/learn-about-standards-guidelines/magazines-newsletters/the- standard/January-2020/Understanding-the-therapeutic-nurse-patient-relationship/ Scheinberg, D. (2019). Dr. Andrew Weil’s Eating Well Plan. Dr. Andrew Weil’s Eating Well Plan By: Scheinberg D, Health Library: Evidence-Based Information, March 1, 2019 , 1. https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/ login.aspx?direct=true&db=nup&AN=2009867340&site=eds-live&scope=site Schub, T. (2018). Patient Education: Implementing Appropriate Teaching Methods. Patient Education: Implementing Appropriate Teaching Methods , 5. https://eds-a-ebscohost- com.chamberlainuniversity.idm.oclc.org/eds/pdfviewer/pdfviewer? vid=6&sid=c98e6737-cf2c-4ee9-a29a-d3126534687a%40sessionmgr Markotiü, V. (2020). THE POSITIVE EFFECTS OF RUNNING ON MENTAL HEALTH. The Positive Effects of Running on Mental Health. , 32 (2), 234. https://eds-b-ebscohost- com.chamberlainuniversity.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=5&sid=eaddf2f8- c18d-4f8e-bae6-528663dbfe87%40pdc-v-sessmgr