Health History and Physical Assessment of Random Patient Essay

GENERAL INFORMATION

Patient Name: R. H                                            Name/Initials of Examiner: T. N

Gender: Female                                                  Source of Referral: A neighboring clinic

Source of History/Reliability: The Patient         Date: June 22 2022.

PROBLEM LIST (list active and inactive diagnoses)

Ovarian cysts

Diabetes type 2 Mellitus

Hypertension

Cancer

Cardiovascular diseases

SUBJECTIVE DATA

CHIEF COMPLAINT (CC):  “Urinating is burning and painful.”

HISTORY OF PRESENT ILLNESS (HPI): The client, R. H., is a 28-years old African American woman. She is presented to the clinic with burning and painful urination. The client also reports unusual urinating frequency, a strong urge to void, and minimal urine output. Her urine has a foul smell and looks cloudy. She further reports abdominal pain, which increases with the urge to urinate. The abdominal pain eases after voiding but returns with the urge to urinate again. The client also reports a high fever that reduces for about 5 hours after taking Ibuprofen. However, the fever returns as the medication wear off. The client reports experiencing these symptoms for the past three days. R. H also reports experiencing headaches occasionally, which she relieves with Tylenol. The client denies blood in the urine, vaginal discharge, pain during sex, or irritation or itching around the vulva and vagina. Denies chills, night sweats, weakness, or fatigue. She reports being sexually active. She has had one intimate partner for the past five years.  Health History and Physical Assessment of Random Patient Essay

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PAST CHILDHOOD ILLNESSES: Seasonal asthma.

PAST MEDICAL HISTORY (PMH): Ovarian cyst diagnosed in September 2018.

PAST SURGICAL HISTORY (PSH): No surgical history.

ALLERGIES: No known drug or food allergy. The client reports a childhood allergic reaction toward pollen grains and dust.

UNTOWARD MEDICATION REACTIONS: No drug reaction history.

IMMUNIZATION STATUS: All childhood immunizations are up to date. The client received flu immunization in 2017 and COVID-19 vaccination in 2020.

SCREENING TESTS: Undergoes Pap test and mammogram annually since 2017.

FAMILY HISTORY:

Father: Alive with diabetes type 2 Mellitus (T2DM) and alcoholism history.

Paternal grandfather: Died of cardiovascular arrest at 75 years.

Paternal grandmother: Died of hypertension.

Paternal Uncle: Alive with no known health condition.

Paternal Auntie: Alive with asthma

Mother: Alive and was diagnosed with hypertension and breast cancer.

Maternal grandfather: Died of prostate cancer at 87 years.

Maternal grandmother: Alive with T2DM and hypertension.

Maternal Uncle: Alive with alcohol addiction.

Maternal auntie: Alive and verbally abusive.

Elder brother: Alive with a history of hypertension.

Younger brother: Alive with no known health condition.

Elder sister: Alive with a history of asthma.

Younger sister: Alive with substance use disorder history.

Daughter: 2yo and healthy.

The diagram below illustrates family members and their respective health conditions.

PERSONAL/SOCIAL:

The client is married and lives with her husband and their 2yo daughter in a four-bedroom mansion constructed on the city’s outskirts. She is a lawyer, and with her husband, they own a private law firm which operates in the city. Additionally, the client is a part-time student pursuing a Master’s Degree in Law. She enjoys attending to her clients and ensuring that everybody finds justice. She also mentors young ladies interested in becoming a lawyer in the future. The client is a Christian and participated actively in church activities, including singing in the choir. The client likes engaging in physical activities and spends most of her time at the gym or the swimming pool. She also likes spending leisure time with her husband and their daughter. They go out together for dinner over the weekends or on public holidays. The client denies smoking or using tobacco. The client is a social drinker and takes 3 to 4 beers when she goes out with her family over the weekend or on holidays. She also takes a glass of wine while making dinner once or twice weekly.

FEMALES:  Her LMP was June 17, 2022. The client has a regular and light cycle of 28 days. Her menses last for three (3) days, accompanied by abdominal pain, which is more severe on the first day and mild on day three. She visits her gynaecologist once annually for a Pap test and mammogram. Gravida 1, abortions 0, age of menarche 13 years.

SEXUAL HISTORY: The client is heterosexual. She has been married and has had one sex partner for the last five years. She engages in unprotected sexual relations. She is on contraceptives.

MEDICATIONS:

Ibuprofen 1 g orally every 6 hours taken to relieve fever.

Tylenol 500 mg 2 pills orally every 6 hours taken to relieve occasional headache. Health History and Physical Assessment of Random Patient Essay

Review of Systems:

General: The client reports fever. Denies chills, night sweats, weakness, or fatigue.

Skin: She denies cracking, discolouration, or dryness.

HEAT:

Head: Denies head injuries, lesions to the scalp, head trauma, or scars.

Eyes: Denies blurred vision or double vision.

Ears: Denies hearing loss, ear drainage, or ear pain.

Nose: Denies nasal congestion. Denies difficulty with smelling food.

Throat: Denies swallowing difficulty.

Breasts: Denies breast masses or tenderness.

Respiratory: Denies wheezing sound.

Cardiovascular: Denies shortness of breath or chest tightness.

Gastrointestinal: Reports abdominal pain. Denies change in bowel movement or blood in the stool. Denies vomiting, diarrhoea, or constipation.

Genitourinary: Reports burning and painful urination, unusual urinating frequency, strong urge to void, and minimal urine output. Reports foul-smelling and cloudy urine. Denies blood in the urine, vaginal discharge, or irritation or itching around the vulva and vagina.

Peripheral Vascular: Denies numbness or tingling.

Musculoskeletal: Denies reduced motion or muscle stiffness.

Neurologic: Denies general weakness, dizziness, or memory loss.

Hematologic: Denies anaemia or other blood disorders.

Endocrine: Denies cold or heat intolerance.

Psychiatric: Denies insomnia, anxiety, or suicidal thoughts.

OBJECTIVE DATA

Physical Exam

Vital signs: T 97.4*F; B/P-128/80; HR RR 20, Pulse Ox 97%; W 120 lbs, H 63 inches; BMI score of 21.3.

General: General: The client is a 28-years old African American woman. The client looks younger than her actual age and appears to be healthy. She is well developed, properly groomed, and well-nourished. She is appropriately dressed for today’s weather and time of the year. The client is attentive throughout the clinical interview and maintains eye contact. She answers all interview questions correctly. The client sits upright during the interview and does not seem to be easily disrupted. She does not appear to be in acute distress. She is alert and oriented to events, places, times, and situation. Her self-reported mood is fantastic. Her judgment is good, and she is future-oriented. The client speaks in a low tone, and her affect is appropriate. Health History and Physical Assessment of Random Patient Essay

HEAT:

Head: No injuries or deformities to the scalp. Long and evenly distributed hair was noted.

Eyes: Equally round pupils and sensitive to light.

Ears: No drainage present in external auditory canals. Symmetrical bilaterally.

Nose: Turbinates not inflamed with moist and pink nasal mucosa.

Throat: Good dentition in the mouth with moist and pink oral mucosa.

Neck: No lymphadenopathy noted. Non-tender on palpation.

Chest/Lungs: No respiratory difficulty signs. No wheezing sound. Symmetrical chest expansion.

Heart/Peripheral Vascular: No murmurs, gallops, or rubs were heard. Regular heart rate and rhythm.

Abdomen: Non-distended and non-tender abdomen. Bowel sounds are heard in the four quadrants.

Genital/Rectal: No blood in the stool or urine.

Musculoskeletal: Suprapubic region was tender on palpation. Assessment of rectal and pelvic was deferred.

Neurological: Strength detected on all four extremities.

Skin: Smooth skin with no discoloration or cracks.

Diagnostic results:

1. Dipstick urinalysis results: Leucocyte esterase and nitrite were positive
2. Urine culture: Waiting for results

ASSESSMENT

Based on health-related information provided by the client, physical examination results, and diagnostic tests, three potential diagnoses for this client, starting from the most likely to the least likely diagnosis, are listed below.

1. Urinary tract infection (UTI) – Primary diagnosis
2. Acute Pyelonephritis

• Vaginitis

1. Overactive bladder Health History and Physical Assessment of Random Patient Essay

Primary Diagnosis

Urinary tract infection (UTI) is the primary diagnosis for this client. According to Tang et al. (2019), UTI is characterized by various clinical manifestations, including suprapubic tenderness, dysuria, urgency, frequency, painful and burning urination, a small amount of urine, and a persistent and strong urge to urinate, strong-smelling urine, and urine that appears cloudy. Upon visiting the clinic, the client reports these symptoms, including burning and painful urination, unusual urinating frequency, strong urge to void, minimal urine output, and foul-smelling urine that looks cloudy. Additionally, the client reports a high fever that reduces for about 5 hours after taking Ibuprofen. According to El-Radhi (2018), fever is a key symptom in infectious infections. A high fever indicates an infection in the body. Therefore, UTI qualifies as the primary diagnosis for this client.

Differential Diagnosis

The first differential diagnosis for this client is acute pyelonephritis. This condition is characterized by chills, fever, pain on the back, side, or groin, nausea and vomiting, dark, cloudy, bloody urine, painful and frequent urination, urgency, and foul-smelling urine (Feggi, 2018). The client qualifies for this diagnosis since she reports symptoms of this condition, including high fever, abdominal pain, painful and frequent urination, urgency, and foul-smelling urine. Nonetheless, pyelonephritis is ruled out since the client denies significant clinical manifestations, including chills, nausea and vomiting, and bloody urine.

The second potential diagnosis for this client is vaginitis. This condition is characterized by a change in odor, color, or amount of vaginal discharge; vaginal irritation, pain during sex, light vaginal bleeding, and painful urination (Baptista & Eleutério, 2020). R. H might have this disorder since she reports some symptoms attributed to vaginitis, including painful urination. However, vaginitis is ruled out since the client denies significant symptoms of this condition, including blood in the urine, vaginal discharge, pain during sex, and irritation or itching around the vulva and vagina opening.

Overactive bladder is the last differential diagnosis for this client. This condition is characterized by a sudden urge to urinate that is uncontrollable, urgency incontinence, frequent urination, usually urinating more than eight times in 24 hours, and nocturia (Raju & Linder, 2020). The client qualifies for this diagnosis since she reports symptoms, including a sudden urge to urinate and frequent urination. However, an overactive bladder is ruled out in this client due to the absence of significant symptoms, including urgency incontinence and nocturia.

THE PLAN OF CARE

Treatment of Urinary tract infection (UTI) involves pharmacological and non-pharmacological interventions. Antibiotic medicines (fluoroquinolones), including ciprofloxacin (Cipro) or levofloxacin, should be prescribed to the client due to their safety and efficacy in treating bacterial infections (Cao et al., 2021). Additionally, the client should be advised to continue taking Ibuprofen to relieve fever. According to de Martino et al. (2017), Ibuprofen is effective and safe for relieving adult fever and pain. Hence, continuing Ibuprofen will relieve the client’s fever. Health History and Physical Assessment of Random Patient Essay

On the other hand, non-pharmacological treatment for this client involves patient education. The client should be advised to practice good personal hygiene. She should always put on cotton underwear and dry them completely after washing them. The client should also wipe herself front to back to avoid transmitting bacteria from the anus to the vaginal area. Furthermore, she should increase her water intake to flush bacteria out of the urinary tract. Finally, the client should empty the bladder frequently in less than three hours and ensure that all urine is emptied.

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References

Baptista, P. V., & Eleutério Jr, J. (2020). Diagnosis of vaginitis: time to improve and move on. Jornal Brasileiro de Doenças Sexualmente Transmissíveis; 32(e203214):1-3. DOI: 10.5327/DST-2177-8264-20203214.

Cao, D., Shen, Y., Huang, Y., Chen, B., Chen, Z., Ai, J., … & Wei, Q. (2021). Levofloxacin versus ciprofloxacin in the treatment of urinary tract infections: Evidence-based analysis. Frontiers in pharmacology, 12, 658095. https://doi.org/10.3389/fphar.2021.658095

de Martino, M., Chiarugi, A., Boner, A., Montini, G., & de’Angelis, G. L. (2017). Working towards appropriate use of Ibuprofen in children: an evidence-based appraisal. Drugs, 77(12), 1295-1311. https://link.springer.com/article/10.1007/s40265-017-0751-z.

El-Radhi, A. S. (2018). Fever is a common infectious disease. In Clinical Manual of Fever in Children (pp. 85-140). Springer, Cham. Doi: 10.1007/978-3-319-92336-9_5.

Feggi, L. M. (2018). Acute Pyelonephritis Today. International Journal of Radiology, 5(1), 179-187. DOI:10.17554/j.issn.2313-3406.2018.05.53

Raju, R., & Linder, B. J. (2020, February). Evaluation and treatment of overactive bladder in women. Mayo Clinic Proceedings (Vol. 95, No. 2, pp. 370-377). Elsevier.

Tang, M., Quanstrom, K., Jin. C, & Suskind, A, M. (2019). Recurrent Urinary Tract Infections are Associated with Frailty in Older Adults. Urology; 123:24-27. Health History and Physical Assessment of Random Patient Essay