Patient History and Physical Examination

Patient History and Physical Examination

Introduction

Patient history and physical examination are vital factors that nurses rely on during the diagnostic process. The patient history provides adequate information about the patient that assists in determining the type of disease affecting the patient. Physical examination, on the other hand, contains information about the current patient’s condition that can help in the diagnosis process (Winters et al., 2018). Patient history and physical examination are useful during the diagnostic process of a patient. History and physical examination of infection can be used as an analysis tool for differential diagnosis.

History and Physical Examination

In the case study, the presented patient had a painful history of dull aches that occur when the joints are in motion. The patient has a history of constant physical activities, given that he participates in soccer games. The pain experienced by the patient is insidious since it only occurs when the patient is in motion. The severity of the pain is not intense, and occasionally it is on and off. The joints display a mechanism of tenderness when touching, especially in the area infected by tendinitis (Bannai, Seki, & Shiio, 2019). The patient exhibited mild effusion with a few cases of swelling regions near the infected area. The mechanism of the condition is generally repetitive since it is contributed by a repeated focus on an activity. The patient had surgery on the knee one year ago. The patient explained to have experienced several episodes of knee injury and even elbow injuries. The immediate physical examination was to compare the patient’s painful knee with the asymptomatic knee. The extent of the damage was examined, and some swelling around the injured area was found. The palpation process is conducted to explore the intensity and severity of the pain around the knee (Bannai, Seki, & Shiio, 2019). The depth of the pain was found to be mild, with a dull description. After the performance of the patellofemoral assessment, the patient did not present any signs of effusion in the injured area.

Differential Diagnoses

Differential diagnosis is essential during the diagnostic process to assist in determining the exact infection in the patient. In the scenario under study, the two diagnoses that can be applied to the patient presented to the facility are plantar fasciitis and acute compartment syndrome. The two diagnoses are selected since they both affect the joints and alter the movement process. The two diagnoses are associated with pain since they tend to induce pain in the body’s infected body (Maatouk et al., 2019). Plantar fasciitis and acute compartment syndrome are associated with swelling of the infected region with the body part. The physical examination of the plantar fasciitis condition includes the patient walking with their foot at an equine position to avoid placing pressure on the infected area. Palpation of the region will induce sharp and stabbing pain in the patient. Plantar fasciitis exhibits mild discomfort, which intensifies if the patient continues to walk without treatment. Acute compartment syndrome presents a pain history that appears out of proportion. The pain is always described as burning and often happens to be sincere and aching. The physical examination of acute compartment syndrome involves the analysis of the pain and the inspection of the infected area (Maatouk, Arbel, Sorouri, & Amasay, 2019). The examination is to determine if the condition appears normal or shows signs of atrophy. The palpation process involves checking of the extent of the pain induced in the infected area. The pain and the tense palpation in the infected region suggest the condition of acute compartment syndrome.

Conclusion

The use of differential diagnoses in the nursing practice is essential in identifying the exact infection in a patient. The nurse depends on differential diagnosis, patient medical history, and physical examination to determine the type of pathogen that might have infected the patient. The use of the condition assists in improving the patient treatment process.

Reference

Bannai, T., Seki, T., & Shiio, Y. (2019). Pain in the neck: calcific tendinitis of the longus colli muscle. The Lancet, 393(10185), e40.

Maatouk, M., Arbel, V., Sorouri, M., & Amasay, T. (2019). Case Presentation for Supraspinatus Tendinitis and Lateral Epicondylitis. In International Journal of Exercise Science: Conference Proceedings (Vol. 2, No. 11, p. 40).

Winters, M., Bakker, E. W. P., Moen, M. H., Barten, C. C., Teeuwen, R., & Weir, A. (2018). Medial tibial stress syndrome can be diagnosed reliably using history and physical examination. British Journal of Sports Medicine, 52(19), 1267-1272.

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Goal:

To conduct an assessment of health promotion while applying the nursing process and evidence-based research to disseminate findings to course colleagues.

History and Physical Examination

Case:

Jessica is a 32 y/old math teacher who presents to the ER with a friend for evaluation of a sudden decrease of vision in the left eye. She denies any trauma or injury. It started this morning when she woke up and has progressively worsened over the past few hours. She had some blurring of her vision one month ago and thinks that may have been related to getting overheated since it improved when she was able to get in a cool, air-conditioned environment. She has some pain if she tries to move her eye, but none when she just rests. She is also unable to determine colours. She denies tearing redness, or exposure to any chemicals. Nothing has made it better or worse.

She denies fever, chills, night sweats, weight loss, fatigue, headache, changes in hearing, sore throat, nasal or sinus congestion, neck pain or stiffness, chest pain or palpitations, shortness of breath or cough, abdominal pain, diarrhoea, constipation, dysuria, vaginal discharge, swelling in the legs, polyuria, polydipsia, and polyphagia.

The patient is alert; she appears anxious. BP 135/85 mm Hg; HR 64bpm and regular, RR 16 per minute, T: 98.5F. Visual acuity 20/200 in the left eye and 20/30 in the right eye. Sclera white, conjunctivae clear. Visual fields on the left side are not assessed; visual fields on the right eye are intact. Pupil response to light is diminished in the left eye and brisk in the right eye. The optic disc is swollen. Full range of motions; no swelling or deformity. Mental status: Oriented x 3. Cranial nerves: I-XII intact; horizontal nystagmus is present. Muscles with normal bulk and tone; Normal finger to nose, negative Romberg. Intact to temperature, vibration, and two-point discrimination in upper and lower extremities. Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achilles tendons; no Babinski.

Complete a comprehensive history and Physical Examination.

What physical findings are you looking for to help determine a presumptive nursing diagnosis?

Support your findings with peer-reviewed articles.

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