Demographic Data
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I interviewed a male patient called C.P., a 26-year-old male of mixed race of Haitian and Salvadorian descent. C.P. was compassionate and collaborative and gave accurate answers during the history-taking process. The precise information from C.P. was due to explaining the method to the patient before beginning the process. The patient provided accurate bio data. The patient’s bio data includes the patient’s residence. For example, C.P. resides in Margate, Florida, with his partner. C.P. works as a carpenter and spends nearly half the week working. The patient also stated that he has health and dental insurance.
Perception of Health
The patient often associates good health with being able to attend to daily activities. He states that living in good physical status indicates a good life. However, the patient claimed that mental and social disorders are not measures of personal health. In addition, the patient added that being able to eat indicates good health. The patient also added that individuals with good eating programs and healthy dietary food live healthy lives. Secondly, he relates a good diet as a primary determinant of an individual’s physical fitness. He told those attending the gym to have the best diet and health status. The patient also thinks it is healthy to communicate with people and talk through things clearly and without irrational thinking. The patients stated that living an unhealthy life is marked by a sedentary lifestyle and life that is always associated with recurrent or chronic illness. Finally, the patient claimed that those with high body mass index (BMI) live a good quality of life. However, he links them to developing “rich man’s” diseases like hypertension, diabetes, and cancers.
Past Medical History
The complete patient examination begins with discovering the patient’s medical history and history of the ongoing illness. Evaluating the patient’s past medical history helps understand the patient’s risk factors for the current medical condition and supports patient-centered care. For example, C.P. reports having chickenpox during his childhood and reports receiving complete medication and post-exposure vaccinations. Secondly, the patient stated that he had had a previous history of emergency appendectomy from complex appendicitis. The patient also narrated to have had minimal injuries through his going to school; however, he has a history of hitting his left thumb on the table, leading to disturbed left arm numbness. In addition, the patient stated that he had a history of surgery where he had stitches on his forehead above the eyebrows after hitting his head on the edge of a table. Finally, the patient reports a minor injury in the left thumb during a high school football game that was successfully repaired through surgery.
Family history
The patient examination involves the evaluation of the patient’s family medical history. The need to intrude into the patient’s family history is to help evaluate the presence of any chronic genetic disease within the family. For example, C.P. narrated that his aunt had a history of a long struggle with bipolar disorder and schizophrenia. Since he is a close member of the family, he has a higher susceptibility to developing other related mental disorders. Secondly, C.P. added that his father died of hypertension and diabetes two years ago. Being the first-line family member is highly predisposed to inheriting the disease from the father and thus should be followed up for hypertension and diabetes.
Systemic Review
During the systemic assessment, the C.P. cooperated and gave honest answers. My interaction with C.P. was a review of all body systems to determine the presence of any disease or disability. The patient denies the presence of loose hair. C.P. states no hair loss, change in hair texture, or dryness. C.P. responded and admitted the presence of dandruff and an itchy, flaking scalp in recent days. Secondly, during the head assessment, the patient denied the presence of headaches or dizziness. However, the patient admits the presence of previous head injuries during childhood. The patient states the absence of any recent severe head injury or complication of earlier injuries. During the visual assessment, the patient said there was an absence of blurriness, blind spots, and discomfort. During the on-ear evaluation, the patient denied the presence of earaches, had a history of infections, and had hearing loss.
On dental review, the patient admits the presence of occasional bleeding gums while brushing and flossing and occasional ulcers. The patient states the absence of tumours, lumps, or infected lymph nodes in the oral cavity. During the cardiovascular assessment, the patient said there was no adverse condition. On respiratory assessment admits the presence of occasional shortness of breath and difficulties in breathing. After reviewing any previous history of respiratory disease, the patient stated that there were no ailments such as asthma, emphysema, bronchitis, pneumonia, and tuberculosis.
Objective Data
On the assessment of HEENT, the C.P. had an average head circumference. C.P. admits the presence of a lump on the forehead from an old injury. However, he denies the presence of opened sores, tender spots, and any present injury. On facial assessment, C.P. had normal facial symmetry and denied drooping, weakness, and involuntary movements. The patient had normal conjunctiva papillary, sclera, and pupil responses during the eye review. The patient presents with a normal ear pinna. Upon assessment, the patient denies any apparent masses, lesions, tenderness, or discharges from the ear. The external ear canals resemble white, with no redness, swelling, lesions, foreign bodies, or discharge.
Neither side of the head disserved were monaural soft sounds heard. In addition, they had normal nose symmetry and no deformity. In the mouth, the patient presented with pink mucosa. The patient denies the presence of any discharge or deviation in the septum. Secondly, the patient had malocclusion and misalignment of the dental formula. The patient reported no obvious fistulous openings or oral lesions. The patient had normal gingiva; all teeth were counted without fillings or cracks. The patient’s tongue was smooth and pink, with no lesions. In addition, the patient had a pink throat, no lesions, and no exudation detected.
The patient states the absence of neck pain and any apparent neck masses. The patient’s anterior neck was symmetric, with the trachea in the midline and the carotid centrally placed. There were no palpable lymph nodes in the neck. The patient states the absence of abnormal neck distention. On percussion, the patient had normal bilateral resonant. Respiratory system assessment: C.P. denies the presence of cough, rhinitis and tonsillitis. On assessment, C.P. presented with normal and clear breath sounds. Tactile fremitus was heard and normal. In addition, vocal resonance was normal.
On cardiovascular assessment, C.P. states the absence of chest pain during slight activities, orthopnea, vibration, and easy fatigability. Secondly, C.P. did not present with increased jugular vein pressure, peripheral oedema, and no enlargement of thoracic veins. C.P. has normal pulse pressure, rhythm, thrill and average pulse rate. The patient’s heart sounds were typical in the cardiovascular system, with no murmurs or irregularities. On neurological assessment, the C.P. had a normal orientation regarding time, place and person. He also responded appropriately to the conversation. C.P. presented with essentially normal cranial nerve functions. He also denies the presence of hearing loss loss of taste and balance. In addition, during the assessment, C.P. denies the presence of abdominal pain, bloating, diarrhoea, nausea and vomiting. He also states the presence of stool bulk and consistency and denies the presence of constipation and rectal and anal bleeding. On peripheral vascular assessment, C.P. denies the presence of peripheral venous enlargement, negative signs of DVT, varicose veins and a previous history of leg ulcers. During musculoskeletal the assessment, C.P. denies the presence of muscle weakness and joint pains, he stated to have normal gait and muscle power on both opposite limbs to be equal. He presented with average muscle bulk and tone. During the evaluation, there was no apparent skin dryness or scaling. C.P. denies the absence of itchy skin, hyper/hypopigmentation and changes in skin hair distribution. During the urinary system review, C.P. rejected the presence of hematuria, urine urgency, frequency, and hesitancy. He also rejected the presence of a previous history of STIs and UTIs.
Development Consideration
In his sixth-grade state, he was not interested in schooling as much as he wanted to be with his friends and hang out, which made him stay behind for one more year. However, the home where he lived was not stable either. He observed that his family struggled financially, which made him unselfish, and he used this opportunity to go out and do things on his own. The patient says he was among the group of ones who became reckless, prone to the use of drugs and alcohol abuse, but also because of fighting.
Cultural Consideration
The patient stated that he used to attend church in his teen years and be part of religious gatherings and bible study with his church members. However, the patient narrated that he stopped going when he lost his transformation belief. This was attributed to his mother performing rituals against the Haitian culture. He asserts that his fatherland, Salvadorian culture, had made little difference for him.
Psychosocial Consideration
C.P. is a high school student dropout. He stated this was attributed to his mother developing a stroke and, leading him to depression. He said that in his post-depression era, he could not go back to school. He is a younger brother among his four older brothers and is responsible for caring for his ageing mother. He also narrated that he did not expect caring for his mother to be as tricky as it turned out. He said he learned carpentry skills when his elder brother returned home and started caring for their mother.
Reflection
According to Potter et al. (2021), patient assessment is critical in diagnosing and developing a management plan. When taking patient history, it is essential to consider all the positive findings to create an accurate diagnosis. During my examination of the patient, I developed a good patient history. Patient history is based on the presenting complaints, history of presenting illness, past medical and ongoing medical history, objective information from the patient on systemic reviews, and physical examination findings (Giger & Haddad, 2020). Secondly, during the patient assessment process, I utilized the knowledge I had gained from the health assessment class. My medical interview and assessment focused on evaluating the patient from his childhood to his current health condition. In addition, during the examination, I examined the C.P. on social, economic, and family factors that could influence his current health status. Thirdly, I evaluated C.P.’s history of past medical illness and ongoing illness to evaluate the need for a comprehensive patient medical approach (Potter et al., 2021).
In obtaining the patient’s consent, I had to inform the patient that all of his information would be kept private and that he would answer all of my questions directly and accurately to ensure that I came up with an accurate and reliable assessment report. Giger and Haddad (2020) stated that the need to seek patient consent is help in ensuring medical ethics are maintained. Seeking the patient’s consent gives room for the autonym of the patient and assures the patient of the confidentiality of any shared information (Jarvis, 2023). I prefer to concentrate on positive findings collected from the patient as a significant priority. When collecting a patient’s history and conducting an assessment, it is essential to focus on the positive and find a way to facilitate excellent plan formulation (Giger & Haddad, 2020). Firstly, the patient’s dental health had a positive finding of bleeding gums whenever he brushed and flossed. The bleeding gum finding could be attributed to gum disease and poor blood coagulation. Secondly, on the patient’s social and developmental history, the C.P. reported a history of absence from the family. The patient’s inability to live with the family in the early stages of life indicated poor social life, which could subject him to developing poor social health conditions and possible mental conditions such as depression (Jarvis, 2023). Finally, I found the interview challenging in the initial steps; however, it ended up being easy as I moved along since I established a good rapport with the patient during the initial hours.
References
Giger, J. N., & Haddad, L. (2020). Transcultural nursing-e-book: Assessment and intervention . Elsevier Health Sciences.
Jarvis, C. (2023). Physical examination and health assessment-Canadian E-book . Elsevier Health Sciences.
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2021). Fundamentals of nursing-e-book . Elsevier Health Sciences.
