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This assignment has two steps health assessment and power points on subject
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Health and Physical Assessment
Details of the Assessment
O Date: 22rd Feb 2017
O Age: 72
O Sex: MALE
O Time: 08:00AM
Chief Complaint (CC):
• “The patient complains of chest discomfort. This is
discomfort majorly in the center of the chest a lasts
for few minutes” “ this trouble comes in the form
of pain, uncomfortable pressure and squeezing”
• “The patient is complaining of upper body
discomfort which entails discomfort or pain in one
arm, jaw, back or the stomach.”
• “He has experienced shortness of breath which
tends to occur before or during chest pain”
• “Other complaints are that he experiences nausea
and rapid sweating.”
History of Present Illness (HPI
O The disease started two weeks ago, the situation getting
worse each day and the patient did not visit any health
care facility to report the disease, the symptoms seem to
discomfort in the chest region and the abdomen majorly.
O The patient started experiencing breathlessness swelling
in legs, ankles, and feet.
O There are no alleviating factors, but there are
aggravating factors such as hypertension. Other
pertinent negatives include peptic ulcer disease and
pneumonia.
O The patient had been diagnosed with lipid disorder
earlier, but there were no diagnostic testing that was
related to the current illness done
Medications and Medication
Intolerances::
O These medications are for treatment of heart
failure in early stages to prevent further damage to
the heart.
O They include drugs like Angiotensin-2 to halt fluid
accumulation in body tissues and use of Thiazide
diuretics to lower blood pressure.
O The patient should take 10mg daily of each drug
O Medication intolerance entails an adverse reaction
of the patient towards any medicine. The patient
has medical intolerances to some antibiotics which
include penicillin and amoxicillin
Past Medical History (PMH)
Allergies (Drugs, Food, and
Environmental):
O The patient is allergic to drugs such as
penicillin and amoxicillin; he is also allergic to
pork and any related products.
Environmentally the patient is highly allergic
to pollen
O Tobacco, alcohol, or illicit drug use in the past:
O The patient has been smoking since his early
20s with the average consumption of alcohol.
O He has engaged in use of any illicit or hard
drug
Chronic Illnesses/Major
traumas
O The major traumas that the patient suffers are
three major gunshots on his upper limb that
have affected his walking.
O Though they do not affect his ability to walk
independently, the patient cannot walk for long
distance.
History of any illness:
O
Childhood:
The major injuries that the patient suffers are three major gunshots on his upper limb that have affected his
walking. Though they do not affect his ability to walk independently, the patient cannot walk for long
distance.
O
Adult:
The patient at the age of 50 was diagnosed with lipid disorder. The disorder has been prevailing up to the
date of this assessment. Until recently, he has not been diagnosed with any other major illness.
O
Ob/Gyn:
There are no cases of obstetrics or gynecology since the patient is a male
O
Psychiatric:
After the patient had been attacked by armed individuals who shot him severely on his legs, he was
hospitalized for some time. He developed depression about his security and the intentions of the armed
bandits. He was also stressed whether he would walk again. The psychiatric report, however, showed that
the patient managed to get over his situation and state of reasonable conduct was reported
O
Hospitalizations/Surgeries:
The patient has been hospitalized and had surgery on his left limb due to gun shots. He has been diagnosed
with asthma at the age of 10 and 12. Lipid disorder has been prevailing since the patient was 55 years
through current time.
Social History
O The patient is a certified accountant holding a degree in
accounting. He is a prosperous employee having worked for five
organizations during his career days.
O During the occupation period, the patient has risen to high
positions and ranks within the organizations he has ever worked.
He lives a middle-class life with his wife and two children.
O He has been a smoking tobacco since his teenage and
consumption of alcohol. The patient lives in a safe neighborhood;
upon an assessment of the patient’s home, it looks neat though
there are a lot of cigarettes remains in the garbage pit.
O The patient is financially well since he receives pension payment
from his previous employer. Hence he is capable of financing for
hid food and medication among other expenses
ROS
O General
The weight of the patient is increasing with the patient
experiencing fatigue, especially on arms and legs. There
are night sweats and reduction of energy level on the
patient
O Cardiovascular
The patient is experiencing chest pain
O Skin
Delayed healing, rashes, bruising, availability...