Health History and Physical Examination of the Patient

Chief Complaint

Mary is a 35-year-old woman who presents to a hospital with her main complaint of rashes on her face and the bridge of her nose during the last one week.

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History of Present Illness

The patient reports that her first rash appeared after her one-week camping in the Appalachians. Her lesions are painful and itch, and going outdoors makes the situation worse. With time, the patient starts bothering from weight loss, fatigue, fever, muscle ache, and pain in the hand and wrist.

Past Medical History

The patient denies any hospitalization. At the age of 9 years, she had a tonsillectomy because of chronic strep throat infection.

Family History

Father: a healthy person.

Mother: a history of rheumatoid arthritis.

Children: Mary does not have children.

Social History

Neither smoking nor drug history is reported. A glass of wine is drunk almost every night during her dinner. Mary is an electrical engineer with a master’s degree in engineering. She has stable relations with her boyfriend that have been lasting during the last five years. They live together.

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Medication History

No information is given.

Allergies

NKDA

Review of Systems

Constitutional: The patient complains of fatigue, fever, and weight loss. No headache, polyuria, polydipsia, or polyphagia.

HEENT: normocephalic, atraumatic. No sore throat, ear pain, or nasal/sinus congestion.

Eyes: White sclera and clear conjunctivae; pupils’ constriction from 4 to 2 mm.

Throat: mouse soreness; moist oropharynx, erythema in the posterior pharyngeal wall; shallow ulcers in the buccal mucosa bilaterally.

Neck: no cervical lymphadenopathy.

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Skin: erythematous plaques scattered over the cheeks and the nose bridge. No rash on the nasolabial folds. No exudates.

Cardiopulmonary: No chest pain or shortness of breath; no swelling or deformity.

Musculoskeletal: muscle pain in the hand and wrist; a full range of motion; muscles with normal bunk and tone; no early morning joint shiftiness.

Physical Examination

Vital Signs

BP: 112/66; HR: 62; RR: 12; T: 100.3.

General

During the examination, Mary is defined as an alert young woman who sits comfortably on the examination table.

HEENT: PERRLA. Throat: shallow ulcers in the buccal mucosa.

Skin: rash on the patient’s face and nose bridge.

Neck: supple without cervical lymphadenopathy or thyromegaly.

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Heart: regular rate and rhythm.

Lungs: no shortness of breath.

Abdomen: no pain.

Nursing Diagnoses and Care Plans

  1. Impaired skin integrity related to the rashes on the skin as evidence by the changes in the skin condition on the patient’s face and nose bridge.

The inflammation process usually affects different organs, including skin, joints, and the nervous system.

Goal: the skin should be returned to its normal condition.

Outcomes: the patient should avoid exposure to sunlight as it triggers a rash.

Intervention: A regular skin assessment should help to identify if new lesions appear and increase and if new skin areas start itching. Rash complications have to be identified at their early stages to avoid heart and lung problems.

Skin cleaning helps to prevent the growth of infection and promote a healing process without making skin injuries. The patient should feel comfortable with every service offered.

  1. Fatigue-related to skin infection and weight loss as evidence by the patient who reports that she is not able to maintain her usual routine.

The patient informs about the increased cases of fatigue she has never observed before in her life.

Goal: to take enough rest and gather enough energy for daily routines.

Outcomes: the patient should identify how fatigue influences her life and discuss with the nurse what can make her fatigue worse. New energy-saving techniques should be introduced.

Interventions: communication between a nurse and a patient to make sure that fatigue does not challenge different parts of the body and her brain. Communication with patients should also be used to educate about the importance of avoiding sunlight and chemicals, no lesions scratching, and no make-up. The explanations of why rest is important: the patient has to understand that fatigue is an important symptom of lupus that cannot be properly treated. Therefore, routine improvements and lifestyle changes should be offered to facilitate health changes and support patients. It is normal to take more rest than usual.

  1. Imbalanced diet related to weight loss as evidence by the fact that the patient loses weight regularly.

Weight loss may influence the work of the whole body and change the mood of a person.

Goal: to stabilize the patient’s weight and stop its changes.

Outcomes: a possibility to achieve a previous weight and stop losing kilograms.

Interventions: An adequate diet should help the patient reduce the number of harmful items in the body, promote health and healthy skin, and take as many necessary vitamins as possible.

  1. Hyperthermia related to infection as evidence by a higher temperature of 100.3, weight loss, and fatigue.

Outcome: the reduction of the patient’s temperature within the next 24 hours. The patient should report on increased energy and the reduction of rash on her face.

Intervention: the assessment of the patient’s temperature orally and the report if it increases. The patient should take as much fluid as possible.

Teaching Plan

Education

The patient should be educated about the peculiarities of rash and fatigue treatment. The main point is that there is no single drug that can help the patient. Therefore, it is necessary to take drugs that help to control different symptoms and reduce the portion of discomfort experienced by the patient. It is not an easy task to live with rash and fatigue, and people have to learn several important rules, including the necessity to avoid sunlight exposure, take as much rest as possible in order not to be challenged by regular fatigue, choose a diet, and do physical exercises to control joint pain. As soon as the patient learns the main steps of treatment, it is high time to explain what other doctors should be visited and consulted.

Referrals

In addition to a consultation with a general therapist, it is possible to address a psychologist to ask for professional help and explanations of how to change an ordinary lifestyle and add more rest to everyday activities. Depression and frequent mood changes may be observed. Therefore, an expert piece of advice is appreciated. Also, it is required to consult a nutritionist and discuss eating habits and changes in case of an emergency. Finally, massage therapy can be offered to a patient, and a referral to a massage therapist is required.

Follow-up

In one week, it is necessary to visit a doctor and inform about possible changes on the skin and in the mood. If the chosen therapy and medications do not cause side effects, it should be kept for one month. If massage therapy is used by the patient, it should be ended in two months to make sure all joints and muscles work properly.

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StudyCorgi. (2020, December 13). Health History and Physical Examination of the Patient. Retrieved from https://studycorgi.com/health-history-and-physical-examination-of-the-patient/

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1. StudyCorgi. "Health History and Physical Examination of the Patient." December 13, 2020. https://studycorgi.com/health-history-and-physical-examination-of-the-patient/.


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StudyCorgi. 2020. "Health History and Physical Examination of the Patient." December 13, 2020. https://studycorgi.com/health-history-and-physical-examination-of-the-patient/.

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StudyCorgi. (2020) 'Health History and Physical Examination of the Patient'. 13 December.

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