Comprehensive History and Physical Examination
Identifying Data
The patient was identified as S. A. The use of initials was considered a necessity to prevent personal data disclosure.
Reasons for Seeking Health Care
Cough and wheezing; shortness of breath; chest tightness.
Chief Complaint
Difficulty breathing, especially at night.
History of Present Illness
The patient addressed the hospital’s staff with complaints of having breathing issues. Particularly, S. A. reported significant troubles breathing, as well as the presence of evident wheezing sounds in their chest. The specified episodes are especially common in the night, and there are immediately followed by continuous coughing. Characteristics: nonproductive dry cough prevents S. A. from sleeping and does not contribute to any improvements only weakening her. The client explained that she experienced especially numerous problems during the night. Aggravating factors include pollen, dry weather, dust, and instances of anxiety. Relieving factors: to reduce the magnitude of the symptoms, S.A. uses a combination of herbal treatment strategies and pain relievers. Treatment: apart from using inhalers occasionally, the patient has not had any treatment so far since she is at the early stage of adult-onset asthma development.
Medication
S. A. has not been subjected to any treatment yet. Hence, no medications have been administered to her so far. The patient has been using herbs to address the coughing issue.
Allergies
The patient is allergic to pollen, dust, cold air, smoke, fumes, animals, and mold. Furthermore, the instances of allergy can be caused by strong scents, in general. For example, S. A. stated that she had a breathing problem after scenting strong perfume.
Past Medical History
S.A. had pneumonia when she was 24. As a young child, she often had a cold and a sore throat, which led to bronchitis. She also had influenza four times (at the age of 15, 18, 19, and 23). The patient claims to have never experienced any difficulties breathing before, though.
Past Surgical History
The patient had an appendectomy at the age of 17. The patient also had a partial mastectomy due to the development of breast lumps. Neither of the surgeries was followed by any complications.
Family History
The patient’s family history does not contain any medical issues that can be defined as possible risk factors for her health. Specifically, there has been no known history of allergies or asthma. The patient’s maternal grandfather developed Alzheimer’s disease at the age of 74, which implies that S.A. may need to consider applying preventive measures against the possible development of the disorder. Particularly, the introduction of physical exercises and a proper diet should be regarded as a necessity. It should also be borne in mind that the patient’s father died at 51 due to lung cancer. The patient’s mother is a social worker in retirement, who has been experiencing musculoskeletal issues, particularly, the effects of osteoporosis.
Social History
S. A. can be described as rather introversive, which means that it is rather difficult for her to establish social connections with the members of her community. She is a professional software developer. Her hobbies include drawing and traveling.
Sexual and Reproductive History
S. A. is heterosexual. The patient is not married and has had only two partners. She currently lives alone.
Health Care Maintenance (HCM)
S. A. rarely uses healthcare services, mostly because her work occupies a significant amount of her time. Furthermore, the patient is reluctant to use medical services because of the fear of experiencing significant pain in the process. Combined with the lack of awareness about the means of sustaining her health, the specified characteristic of the patient is likely to lead to major health concerns unless addressed.
Review of Systems
All of the patient’s systems except for the respiratory one function properly. According to the physical assessment results, the patient’s airways narrow as a result of being exposed to certain factors such as the presence of pollen in the air.
Complete Physical Examination
Vital Signs
Pulse 87, temperature 105°F, blood pressure 119/75, weight 107, height 5’2”, respiration 23, and body mass index (BMI) 19.6.
Mental Status Exam (MSE)
S. A. is properly groomed, her clothes being neat, and her hair is arranged in a simple yet neat way. S. A. articulates her ideas well and is fully aware of her environment and condition, which can be viewed as the sign of her having no mental issues. Similarly, no behavior disorders have been spotted during the examination. Her responses to irritants are adequate and timely. Thus, it can be concluded that S. A.’s state of mind is regular. It should be noted, however, that the patient had certain difficulties when communicating. The specified issue can be explained by the fact that S. A. had breathing issues and had recently experienced a fit of what was presumably asthma. As a result, of the health issue experienced by S. A., she was in distress and, thus, was rather worried (Ferro et al., 2015).
The actions of the patient, as well as her reactions to irritants and articulation of her problem and condition, can be regarded as the signs of her being in a normal state of mind and having no mental concerns. The signs of distress shown by S. A., however, may be the symptoms of developing stress and the threat of possible depression due to an increase in anxiety levels. Thus, it is essential to provide a therapy based on the enhancement of patient education and the provision of detailed instructions to S. A. to help her manage her condition.
The patient’s thoughts are clear and coherent. S. A. is capable of critical thinking and detailed analysis. Thus, it can be assumed that her thought process is coherent.
S. A. also displays regular cognitive functions. While anxiety has a distinct effect on her, she manages to utilize her cognitive skills. Thus, the patient’s mental health status can be regarded as positive.
S. A.’s mental health is not impaired. She can thin coherently and properly. However, the presence of anxiety needs to be addressed (Bruzzese et al., 2016).
Skin
S. A. has a dark complexion and, therefore, is not prone to sunburns. The patient’s response to touch is adequate. Based on the results of the Blanch Test, S. A.’s nails meet the current standards of health. S. A.’s hair is dark brown and curly. S. A.’s hair can be defined as relatively healthy, although it is not thick and is prone to falling out. The observed phenomenon can be attributed to the increase in the stressful experiences associated with asthma, as well as improper dieting (particularly, the lack of protein) (Grond, 2017).
Head
S. A. has a slightly elongated head, which can be described as symmetrical. The head has no signs of injuries. The lymph nodes that are located in the patient’s head are of a regular size.
Eyes
S. A.’s eyes have white sclera, with slight shortsightedness. S. A.’s eyes respond to the motion within a 1-2-second range, which can be regarded as normal. The pupils are enlarged due to shortsightedness.
Ears
The ear canals are of a regular size and color. The eardrums are not damaged. S. A. responds to sounds appropriately and is capable of hearing them at regular frequencies. The Otoscopic test carried out in the hospital setting did not reveal any deviations from the norm (Ting, Huang, & Tzeng, 2016).
Nose and Sinuses
The external portion of the patient’s nose is symmetrical and placed appropriately. S. A.’s nostrils are currently occluded, which can be viewed as a partial reason for the observed difficulty breathing.
Mouth and Throat
The patient’s lips are moist and proportional. The tongue can be described as pinkish, with a geographic texture. The specified characteristic implies that the patient is experiencing inflammation (Radhika, Jeddy, & Nithya, 2016).
Neck
S. A.’s neck has proportional muscle. The patient does not experience any pain when moving her neck. The size of S. A.’s lymph nodes meets the standards.
Respiratory
The patient has approximately 20-23 inhalations-exhalations per minute, which can be explained by the presence of asthma. Significant respiration efforts and uneven movements were observed. The Supraclavicular lymph nodes are palpable.
Cardiovascular and Peripheral Vascular
The pulse rate is 107, which is slightly above the norm. The specified phenomenon can be explained by anxiety and the presence of asthma. There are currently no signs of varicose.
Abdomen
S. A.’s abdomen is symmetrical, with no scars or evident abnormalities. Peristaltic movements are regular and within the normal range. S. A. has no bowel sounds, her stool being regular, and with no signs of either diarrhea or constipation.
Musculoskeletal
S. A. has normal muscle movement. The tissue has no abnormalities in its structure. S. A. does not have any discomfort when moving.
Neurological
Subsegmental lymph nodes are currently plugged. Furthermore, mediastinal lymphadenopathy is observed. S. A. provides adequate responses to questions and reacts to stimuli appropriately. However, there are evident signs of anxiety regarding her current health issue. The specified phenomenon must be addressed fast to prevent further development thereof. The cranial nerves of the patient are regular. CN VIII is intact (Lee et al., 2014).
References
Bruzzese, J. M., Reigada, L. C., Lamm, A., Wang, J., Li, M., Zandieh, S. O., & Klein, R. G. (2016). Association of youth and caregiver anxiety and asthma care among urban young adolescents. Academic Pediatrics, 16(8), 792-798. Web.
Ferro, M. A., Van Lieshout, R. J., Scott, J. G., Alati, R., Mamun, A. A., & Dingle, K. (2016). Condition-specific associations of symptoms of depression and anxiety in adolescents and young adults with asthma and food allergy. Journal of Asthma, 53(3), 282-288. Web.
Grond, S., Radner, F. P., Eichmann, T. O., Kolb, D., Grabner, G. F., Wolinski, H.,… Rülicke, T. (2017). Skin barrier development depends on CGI-58 protein expression during late-stage keratinocyte differentiation. Journal of Investigative Dermatology, 137(2), 403-413. Web.
Lee, Y. G., Jeong, J. J., Nyenhuis, S., Berdyshev, E., Chung, S., Ranjan, R.,… Jarjour, N. N. (2015). Recruited alveolar macrophages, in response to airway epithelial–derived monocyte chemoattractant protein 1/CCl2, regulate airway inflammation and remodeling in allergic asthma. American Journal of Respiratory Cell and Molecular Biology, 52(6), 772-784. Web.
Radhika, T., Jeddy, N., & Nithya, S. (2016). Tongue prints: A novel biometric and potential forensic tool. Journal of Forensic Dental Sciences, 8(3), 117-119. Web.
Ting, C. S., Huang, K. W., & Tzeng, Y. C. (2016). Correlation between video-otoscopic images and tympanograms of patients with acute middle ear infection. Indian Journal of Otology, 22(1), 10-13. Web.