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Pages:
6 pages/≈1650 words
Sources:
5 Sources
Level:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
Language:
English (U.S.)
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Topic:

Comprehensive Patient Assessment: Current Health Status (Essay Sample)

Instructions:

Comprehensive Patient Assessment
When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. It is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting.
all papers submitted include a title page, introduction, summary, and references
Write a comprehensive paper that addresses the following:
Age, race and ethnicity, and partner status of the patient
Current health status, including chief concern or complaint of the patient
Contraception method (if any)
Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
Review of systems
Physical exam
Labs, tests, and other diagnostics
Differential diagnoses
Management plan, including diagnosis, treatment, patient education, and follow-up care

source..
Content:

Comprehensive Patient Assessment
Student’s Name
Institutional Affiliation
Comprehensive Patient Assessment
Introduction
Rodgers Marlene is a female patient who was referred to the emergency department on 6th January 2017 in the evening after the nurse at the reception centre considered her illness being critical and that needed an urgent attendance. She is admitted for a week. The chief complainant presented by Rodgers is deep chest pains which according to her report began a couple of weeks ago. Initially, Rodgers thought that it was due to a cold exposure and that she did not seek medical care immediately since she thought that it would disappear after some time if she kept warm. Her background was also a derailing factor that made her not to seek medical care early in the time since she did not have a convenient means to the healthcare facility and further she lives alone. She comes from a poor family background.
General Patient Information
Rodgers is an elderly woman aged 66. She is a resident of Mississippi State. Rodgers is an African American, and she is black by race. As noted earlier, she is a single woman who lives alone. This came after her husband died about ten years ago after suffering a heart attack at the age of 58.
Current Health Status
Rodgers was admitted to the emergency department for the first time. She explains that her health situation was at normal and usual state before three weeks ago when the illness got worse prompting her admission in the hospital. During that time, the patient became aware of a hasty onset (over a couple of seconds to a minute) of chest pain. She explains the chest pain as being an aching and dull experience. She first felt the pain from her left parasternal section of the chest before it radiated up to the neck area. The first pain occurred to her when she was working on her garden early in the morning when it was still cold. She explains that she had been weeding her vegetables for approximately an hour when she began to feel exhausted before the pain erupted. She could feel shortness of breath. On interrogation, she denies any cases of vomiting, sweating or nausea. She approximates that the pain lasted between 8 and 15 minutes. The pain resolved after she decided to take a rest in her house.
Since that first pain three weeks ago, Rodgers has had three more additional episodes of pain which are similar and equivalent to the former regarding the area of infection and the quality. A week ago, she had a 10-minute episode of pain when she was walking with her pet dog. The pain resolved when she took a rest under a tree shade. Today in the afternoon, the woman experienced an episode of pain that lasted for an unusual longer period she estimates to be about half an hour. She had been taking an afternoon nap before she was awakened by a critical pain that prompted her to visit the medical facility. She has never tried out any treatment measure to her illness other than the deep rest. She states that there were no other symptoms associated with the illness during the three episodes. She denies symptoms such as palpitations and dizziness. She ran short of breath during the episodes but did not experience any orthopnea, exertional dyspnea or paroxysmal nocturnal dyspnea. She also denied any association with the pain with food, movement or GERD. She has never been diagnosed with any heart problem before. She has never had a chest pain either and does not have claudication. However, three years ago she was diagnosed with HTN.
Rodgers does not smoke. She is not diabetic. Three years ago, she was reported to be having hypertension. Six years ago, she had a TAH with BSO. She is not certain of her cholesterol levels, but her family history suggests a history of premature CAD. The patient is not currently under any hormone replacement.
Past Medical Hi...
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