Health Assessment Report With the Elaboration of Diagnostic Reasoning

This current study will reflect on the health assessment and diagnostic reasoning for a clinical case study of a 21-year-old female present in the emergency department.

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Case scenario

A 21-year-old female presents to the emergency department. For six days, the lady has been feeling unwell, experiencing fevers, nausea, vomiting, and diarrhea. The patient has been experiencing pain gradually for three days and the pain is worse in the morning. The patient is experiencing intermittent right flank pain in the middle section and radiation to the back pain. The pain scale is at 7.

Patient background and history

Studies stated that more than 80% of medical diagnosis is taken based on history, a further 5-10% depend on examination and the rest rely on the lab investigations (Epstein et al. 2008). History taking and physical examination stay at the very center of the nursing practice.

Patients Background and history findings during the simulated physical examination was as shown in the table below:

Patient present complain The patient has been feeling unwell, fever, nausea, vomiting, and diarrhea. Pain is 7/10 on the pain scale.

History of present complain

The patient has been feeling unwell for the past six days with three days' gradual pain. The pain is worse in the morning and the pt. has been taking paracetamol as an analgesic. The pt. has been feeling intermittent right flank pain in the middle section and radiation to the back pain.

• Past medical history The pt. has had appendicitis surgical operation
• No previous Asthma, HF, CVA, and DM.
• Family history No family history
• Medication history Other than taking paracetamol for the pain the pt. has no other regular medication
• Allergy No allergy
• Social history The pt. lives with her parents, she is single and works in an office.
• Smoking The pt. does not smoke
• Alcohol Intake The patient drinks one cup every week

Reflection

The areas of strength

Every medical examiner must develop and cultivate the cognitive capacity to perceive what his patient is feeling, and not satisfied with it take action and participate effectively in the reality that is affecting him. Although it sounds basic, first of all, it is important to break the ice barrier, to speak with warmth, cheerfulness, and education to the person before the patient, to make the patient feel that what they are saying is important. Whenever the medical examiner establishes a bond of empathy, they will generate confidence and tranquility in the patient so that he is placed at the mercy of your hands. Every person who comes before the medical examiner is fighting an internal struggle that they do not know. The patient probably has a lot of problems, pressures, and stress that will not tell the examiner a priori, problems that can translate into physical and aesthetic factors, ways of speaking and being, that they may not share. So it is extremely important not to judge the patient before you, give them the freedom to express their somatic feelings without fear of prejudice. Always try not to assume or stereotype, because the moment you judge someone the energy does not flow from you to that person, so you place an invisible barrier, but solid, which prevents the healing the examiner is able to provide.

The areas for improvements

The type of meeting and communication between a medical examiner and his patient is defined as a medical interview. It is one of the most important moments of the consultation because in that time we will give and/or receive a lot of information that may be helpful when it comes to knowing the illness and the treatments in depth. A reasonable time must be scheduled to attend each patient well. The citation of the sick must be properly planned. Avoid wasting patients time. The clinician must be careful to arrive without delays to his consultation. You must also know how to adjust to the schedule. To achieve the best use of available time, it is important to be able to guide the interview, know what to ask and avoid the patient wandering about aspects that do not contribute at all. During the physical examination, aspects of the clinical history can also be specified. The doctor must always maintain an attitude of service and have the serenity and tranquility necessary to offer his care in the best conditions. Also, and although it seems obvious to say it, you must have an adequate professional preparation. If for some reason you do not feel able to help the patient in your problem, you should look for an alternative, either by sending it to a specialist or making him see that he needs to study his problem more thoroughly before being able to advise him. Integrity and honesty must be for a doctor very important aspects of his person.

Health assessment findings

Patients health assessment findings during the simulated physical examination were as shown in the table below:

• A: Airway Airway patent as patient speaking
• B: Minimal apparent effort and a little increase in WBM because of high anxiety levels
• C: Pink perfused
• D: The patient is fully alert
• E: Febrile
• F-IVC- Rt arm
• KVO There was no IVF
• G Not assessed

General Appearance:

• The overall appearance of the patient: alert and able to answer my questions.
• Skin appears sweaty and flushed
• Speech clear
• Emotion status calm
• Hear well
• Normal posture
• No abnormal smells
• Good hygiene

Vital sign:

• BP: 105/70 mmHg
• P: 122 b/ mint
• RR: 19 /mint
• SpO2: 97%
• T: 38.5c
• BSL: not assessed
• Neuro: A+O 3 (alert and oriented to person, place and time)
• GCS 15
• UL/LL strength
• CN's not assessed

HEENT: Face and hair:

• The face is symmetrical no drooping of the face on one side.
• Facial expressions symmetrical no involuntary movements.
• No lesions
• No hair infestations, no hair loss.

Eye:

• No eyelids swelling
• sclera white
• the conjunctiva is pink -not red and no anemia
• pupils clear equal not cloudy
• Normal pupil size 4 mm

Ears:

• No drainage
• Normal tympanic membrane
• Nose:
• Symmetrical in midline
• Nostril patent

Mouth:

• Pink Lips
• No oral lesions
• Dry mucous membranes
• Teeth white and free from cavities.
• No exudate on tonsils

Neck:

• No lesions
• The trachea is midline
• No enlarged lymph nodes
• JVPNR- jugular venous pressure not raised.
• Chest JVPNR
• Normal sentences, with no difficulty
• Symmetrical chest movement lesions
• No tenderness, no scar
• Respiratory rate 19/mint
• Oximetry 97% + on room air

Chest auscultation: quiet, no wheezes or crackle

• heart sounds auscultation: RRR (Regular rate/ rhythm) S1/S2.
• Minimal apparent effort; small Chest / Abdo movement. Increase WBM due to anxiety
• Pulse rate: tachycardia 122 p/mint because of fever and pain.
• Abdomen Last menstrual period before two weeks.
• Normal stomach contour no distension
• Appendicitis scar, no masses, no organomegaly.
• BS present - normal pitch
• Sever pain Rt lumber region
• Renal angle tenderness
• No dysuria
• LL's Normal hair growth
• No swelling, no redness DVT or edema
• CRT < 3seconds
• toenails look normal
• No sores on the feet
• Good joints movement of the toes and knees
• dorsalis pedis (DP) and posterior tibial (PT) not assessed
• Back Not assessed due to the limitation of mannequin
• UL's No deformities
• Rt arm IVC and KVO
• No redness
• No drainage
• Normal hand and fingernails color
• CRT < 3 seconds
• No joints swelling or redness
• Skin temperature hot- febrile
• No clubbing
• Good movement

Reflection

Professional and accurate physical assessment is necessary to decide the status and requirements of the patient and to provide better health care. Professional nurse must be exceedingly skillful in performing the correct physical assessment for the patient to convey high-quality patient care. Physical assessment is an essential skill for the professional nurses. A thorough patient physical assessment is important to comprehend the medical status of the patient, to ensure appropriate medical intervention to be delivered to the patient at the right time (Munroe et al. 2013). Having professional physical assessment skills will give the right result while poor skills will give the wrong result. The first line of the physical assessment is observation, at the first glance to the patient examiner can identify many of medical problems for example (Skin color, respiratory rate and effort, sclera color and lips color). The examiner should use the four skills; inspection, palpation, percussion and auscultation in performing the physical examination (Epstein et al. 2008).

The areas of strength

The Physical Examination is the exploration that is practiced to every person in order to recognize the alterations or signs produced by the disease, using the senses and small devices or instruments such as clinical thermometer, stethoscope, and sphygmomanometer. Before beginning the physical examination, we must create all the conditions previously, which includes the conditions of the premises to the presence of all the material and equipment to be used during the procedure. We must take into account the state in which the patient is to be examined because depending on it, we can manipulate it and/or mobilize it with greater or lesser freedom during the physical examination. When we are in an open room, as long as there is an appropriate room and the patient's conditions allow it, we must perform the physical examination in it, thus guaranteeing the patient's privacy. In the absence of the same, we must isolate the patient from the rest, through a stop. If we are in a room shared with other patients, we must take the precaution of evacuating all those outsiders (companions) from the closed room, and keep the door of the room closed, making use of the same, if necessary. Respect the modesty of the patient: Much in correspondence with the previous precaution, we must avoid the unnecessary exposure of the patient, helping us with the stop and a sheet, to go covering with the latter, the parts that are not examined at the moment. Having the patient as less clothed as possible will guarantee the best action and exploration. In the same way, it is necessary to take into account that the clothes that this has put, allow the good action and exploration

The areas for improvements

Many areas required improvement based on the simulation exam result. However, looking back to the health assessment findings table will show the following area that needs improvement:

Missing to complete the structured physical examination as A, B, C, D is not enough and suppose to address Exposure, Fluids, and Glucose (E, F, and G). Also, the patient was complaining of chest pain (this must stop the examiner and analyze the pain characteristic and think twice before jumping on), Pain Provoking factors, pain Quality, pain Radiation, pain Severity and pain Time factor (PQRST) must be addressed (NSW Health 2011).

Also, physical assessment to the cardiovascular system should be done in a full manner not merely rely on the blood pressure and heart rate result, auscultation to the heart sound must be performed while doing the respiratory assessment, as well as, instant ECG must be performed and interpreted inappropriate manner. if the cardiovascular is free then physical examination can be continued for the rest of the body systems otherwise cardiovascular symptoms have priority and must be treated first.

Also, respiratory assessment must be in more details more than the inspection of the chest and auscultation of the lung sounds, cough characteristics must be examined in details for example (the type of a cough is it dry or productive, timing, increasing and decreasing factors like the semi-sitting position can relie...