Medical Assessment Initial Patient Analysis Chief Complaint

Medical Assessment

Initial Patient Analysis

Chief Complaint

Discomfort in lower back.

HPI

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.

OBJECTIVE

General App.

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.

Bug Bites

Patient may be suffering from a toxic reaction to bug bites, or may be homeless, living outside and being bit, or sleeping in unhygienic areas (bed bugs, etc.)

Foul Odor

Foul odor may be from lack of hygienic living conditions.

Unsteady on Feet

Confusion and potential for malnutrition, diabetic attack, or stroke.

Pill Rolling Tremor

Suggestive of Stroke, Parkinson's, Hyperthyroidism, or certain drugs.

Legs Cool to Touch

Suggesting some sort of arterial disease or diabetes

Low Capillary Refill

Suggests lack of circulation, arterial issue or some sort of blockage

Areas for Focused Assessment- The combination of syncope, vertigo, vision, and memory issues combined with the patient's appearance, odor, and BMI suggest a potential cerebral or arterial issue and inability to receive proper care. 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 pain may be ancillary to event.

2. Cognition -- inability to communicate seems to be in psychological distress and not knowing place, tremors suggest cerebral or chemical event.

Areas of Concern- Primary concerns are the symptoms that indicate blood sugar (diabetes issues) or potential stroke event. Because of the appearance of patient, first steps would be to evaluate with a fasting glucose test and other indicators of diabetic concern. As cardiovascular disease increases in the aging population, older people are more likely to experience a stroke. In fact, age is the single most important risk factor for strokes. However, despite the statistics, it is not inevitable and identification and modifying risk factors in older people, combined with carative advocacy from nurses, can help reduce incidence of stroke. Risk factors are clinically serious after age 75, but can be mitigated. Control of hypertension, management of diabetes, greater adherence to a healthy diet, a regular exercise program, and absolutely no smoking are some of the easier preventatives. In particular, management of cholesterol levels with a balancing of blood-sugar levels combined with exercise seems to be one of the most effective protocols for older adults (Michael, et al., 2006).