ADULT Wellness check up. – nursing homework essays

ADULT Wellness check up.

ADULT Wellness check up.

History & Physical Format

IDENTIFICATION:

Date: 24/09/2021 Time: 10:00 am

Name: M.N Sex: F Race: Hispanic

Marital status: Divorced

Address: Los Angeles, CA.

Tel. 213-509-6995

DOB: 05/11/1985

SUBJECTIVE:

CHIEF COMPLAINT (CC): Annual Wellness Checkup

HISTORY OF PRESENT ILLNESS (HPI): The patient is a 36-year-old female who states that it has been a while since she came for a wellness check-up. She gave birth two years ago and had gestational hypertension. She says she was fine until recently she has been having some symptoms that she does not understand. Over the past two months, she had traveled to Mexico.

The patient complained about mild headaches that are accompanied by pain in the eyes, blurred vision at times, burning eyes, and itching sometimes. The patient has been having those symptoms for a one and half weeks now.

The patient also complains of lower abdominal pains and changes in stool from time to time. The pain is not frequent and come from time to time. Sometimes, the pain is so severe that she has to lay down and take pain medications for her to feel relieved. The abdominal pains have lasted for a month.

PAST MEDICAL HISTORY (PMH): The patient had gestational hypertension during her second pregnancy which had her having a cesarean section. No other complications have been noted.

FAMILY HISTORY (FH): The patient’s mother died 5 years ago of breast cancer. Her father is old and has osteoporosis and is in a care facility. Both of her children are healthy.

SOCIAL HISTORY (SH): The patient drinks alcohol occasionally, does not smoke.

REVIEW OF SYSTEMS (ROS): The patient has red eyes sometimes which are itchy. No history of eye disorders. The patient has changed vision with pain, and frequent headaches. The patient has difficulties with sleep sometimes. The patient has soft stools with blood and mucus occasionally, excessive gas, and rectal pain during bowel movement.

ALLERGIES: No known allergies.

MEDICATIONS: Ibuprofen, Loperamide and Tetrahydrozoline

HEALTH MAINTENANCE: The patient has been healthy, and actively involved in outdoor activities such as playing tennis, hiking, and traveling. The hydrates often go for massages and attend disease prevention conferences. The patient is intelligent and seems to be well informed about basic health issues. She likes to be relaxed and goes for yoga on Saturdays.

OBJECTIVE:

PHYSICAL EXAMINATION (PE):

GENERAL: The patient’s general appearance looks good because the patient is relaxed.

VITAL SIGNS: The patient’s blood pressure is 100/60. The patient is 164 cm tall and weighs 70 kgs. Temperature: 92.3°F. Pulse: 85. Respiration rate:17.

HEENT: No head injuries. The pupils are equal, red eyes with burning sensation and irritation. Eyebrows have symmetrical movement; eye sockets are normally aligned. No strain eye strain. Proper hearing. Pink nasal mucosa. Clear throat and moist mouth.

NECK: Strong. No thyroid mass and lymph nodes. No tracheal deviation. No scars and bruises.

LUNGS: No deformities noticed. Normal chest shape, normal breathing rhythm.

HEART: Normal heart rate and rhythm, no heart murmurs. No heaves, thrills, or lifts were noted.

EXTREMITIES: Full joint motion, no swelling, deformity, and tenderness in extremities.

GENITOURINARY: The patient denies having a burning sensation while urinating, normal urination frequency. The patient denies beading and having abnormal discharge.

SKIN: Skin is warm and has an even tone with good turgor. No bruises, lesions, and rashes were noted.

RECTAL: Tenderness and pain when passing a bowel movement.

NEUROLOGIC: The patient has a normal gait and coordination. Strong reflexes. No LOS, Patient’s sensation is intact. Normal vital signs. Remote memory and short-term and immediate memory are intact.

PSYCHIATRIC: The patient showed proper mood and effect. The patient was alert and oriented.

ASSESSMENT:

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1. Red eyes, irritation and burning pain, congested discharge .It can be indicative of bacterial conjunctivitis.

2. Abdominal pain, diarrhea, occasional blood in stool, rectal pain. It can be caused by bacterial, fungal, or parasitic infection. Mostly suspected is Amoebiasis which is a parasitic infection. The patient had traveled to Mexico which is among the leading places prevalent with Amoebiasis (Saidin et al., 2019).

PLAN:

1. From the patient’s eyes symptoms, it is evident that she has bacterial conjunctivitis which is not responding so well to the over-the-counter antibiotic droplets she is using.

2. We changed the medication from Tetrahydrozoline to chloramphenicol. Chloramphenicol is more effective for conjunctivitis because it works within 4-5 days for both adults and children (Centers for Disease Control and Prevention (CDC), 2019).

3. 1-2 drops of Chloramphenicol 3-4 times a day. Cleaning the sticky eye discharge with sterile wipes. Not to wear eye contact until the symptoms are gone.

4. The patient is required to bring stool samples to be analyzed under a microscope to look for cysts to diagnose the condition. And maybe order for antigen test if need be.

5. The patient should continue drinking a lot of water and maintain high hygiene. The patient will continue with the anti-diarrhea medication (Loperamide).

6. After providing several stool simples, the patient is expected to come back to the medical office after 2 weeks for follow up, or call the office if symptoms get worst.

References

Centers for Disease Control and Prevention. (2019, January 4). Conjunctivitis (Pink Eye). https://www.cdc.gov/conjunctivitis/about/diagnosis.html

Saidin, S., Othman, N., & Noordin, R. (2019). Update on laboratory diagnosis of amoebiasis. European Journal of Clinical Microbiology & Infectious Diseases, 38(1), 15-38. https://doi.org/10.1007/s10096-018-3379-3

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