Medical Assessment Initial Patient Analysis Chief Complaint Essay
Excerpt from Essay :
Initial Patient Analysis
Discomfort in lower back.
Patient is a 78-year-old woman presented as disheveled, with bug bites throughout her body, and exuding a foul odor. Cognitively, she orients only to her name with a BMI of 30 and a minimal understanding of the English language. She is able to nod "yes" or "no" to questions, but calls the nurse "Mother." She is unsteady on her feet, and has a fine "pill-rolling "tremor in her left hand. He legs are quite cool to the touch, hairless, and toe capillary refill is greater than 2 seconds.
Past Medical History
Unknown, but patient appears to be in distress both physically and psychologically.
Poor, disheveled, may not be receiving adequate care or living in an environment with enough food or warmth. BMI of 30 is technically obese, which also may indicate the patient is not receiving adequate hygiene.
Patient may be suffering from a toxic reaction to bug bites, or may be homeless, living outside and being...
...This is based on:
1. Unsteadiness on feet, dizziness, and vertigo -- may be medication, lack of medication, malnutrition, arterial or cerebral issue. Neck and back…
Sources Used in Documents:
Hypoglycemia. (2012). Web MD. Retrieved from: http://symptoms.webmd.com/#./conditionView
Michael, K. And Shaughnessy, M. (2006). Stroke Prevention and Management in Older
Adults. Journal of Cardiovascular Nursing. 21 (55): 521-26.
Mohr, J., et al. (2004). Stroke: Pathopshyciology, Diagnosis and Management. New York: Churchill Livingstone.
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