Taking a Physical Examination SNAPPS History

Running Head: HISTORY TAKING AND PHYSICAL EXAMINATION

HISTORY TAKING AND PHYSICAL EXAMINATION 5

SNAPPS History Taking and Physical Examination

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This patient is a 61-year-old male who presents to the clinic with a chief complaint of uncontrolled blood pressure for a follow-up visit.

HPI statement using OLDCARTS data

The onset of symptoms was 1 year ago and is now progressively increasing.

Lightheadedness and muscle weakness are constant. He experiences a sharp headache in the left temporal region. He reports that the headache is of a throbbing type and rates it at 7/10 using the NPRS. The headache is progressive, accompanied by light sensitivity, nausea, and vomiting. Loss of consciousness associated with the headache is negative. He reports no convulsion but positive for visual changes; further, other special senses are okay except a burning sensation experienced in his eyes. He experiences spasmodic pain and is unable to eat during the headache episodes.

He reports experiencing dry mouth, making it difficult to feed properly due to the pain while swallowing.

The patient experiences joints pains both in the lower and the upper limbs, which he graded 9/10 based on the severity.

The administration of antipyretics and analgesics alleviates the headache. Joint pains were also alleviated by NSAIDS given to him.

The joint pain was aggravated by walking or lifting heavy objects, while the headache was aggravated by upward posture.

Associated symptoms were chills, general body weakness, malaise, night sweats, fever, and insomnia due to his pain.

His past medical history revealed that about a year ago, he was diagnosed with Rheumatoid arthritis; he reports being put on corticosteroid therapy which markedly alleviated the symptoms. This was followed with methotrexate administration which proved ineffective up to the time of visit.

The patient reported having had a hip replacement surgery about 5 years ago.

He reports having completed the vaccination when he was young, including the influenza virus vaccine.

He takes Bystolic 40mg daily, hydralazine 25mg twice daily, and losartan daily due to hypertension. Other medications taken include omeprazole 20mg daily, sildenafil 100mg, and atorvastatin calcium 20mg.

The patient does not have an allergy history.

On his social history, the patient is a graduate of Michigan state university, having attained a degree in Ecology and environment.

He reports sharing a bottle of wine with his wife during daily evening dinner, does exercise regularly, and has not regulated fat and salt consumption.

His family history reveals that his father succumbed to diabetes and hypertension. His mother lives with osteoporosis and hypothyroidism. He has three brothers and one sister with no known chronic illnesses.

Pertinent ROS

General-looked febrile and tired

Head and face-no pain, loss of sensation, traumatic injuries.

Eyes -reports episodes of burning sensation, negative for inflammation, Infections, positive for visual changes.

Neck-no masses, positive for enlarged pre-auricular lymph nodes.

Ears -negative for infections, inflammation, or changes in hearing.

Nose and sinus-No pain, obstruction, or possible discharges, positive for epistaxis.

Mouth and throat -No dental problems, positive for dysphagia, odynophagia, and dry mouth.

Skin -negative for easy bruising, discoloration, hair loss, dry skin, and positive signs in the pre-auricular region.

CNS-positive for lightheadedness, headaches, faints, dizziness, gait disturbances, and slight confusion.

Respiratory system -lung sounds clear, no coughs, shortness of breath, wheezing sound, dyspnea, tachypnea, nasal congestion, and any other respiratory distress.

Cardiovascular system- Negative for chest pains, dyspnea, palpitations, oedema of the lower extremities, tachycardia, increased heart rate, tachypnea, shortness of breath with overall normal breathing patterns.

Gastrointestinal system-negative for abdominal distention, hemoptysis, abdominal pain, vomiting, dyspepsia, and dysphagia but with a slight decline in appetite.

Genitourinary system-positive for hematuria and dysuria, negative urinary incontinence, urine was of normal color, volume, and frequency.

Musculoskeletal system-positive for joint pains, fatigue, and general body weakness, and light back pain.

Pertinent PE

General-blood pressure was markedly raised

Throat-enlarged thyroid gland

Eyes-distended veins and mild hemorrhages.

Heart- arrhythmias noted, unequal blood pressure in both arms, and tachycardia

Lungs-rales note; normal breathing pattern.

Abdomen -normal on palpation and percussion.

Lower extremities-normal.

Musculoskeletal-there was marked muscular atrophy, delayed motor reflex, and slightly delayed perception of pain, temperature, and light touch.

Hematological -there was a marked deficit in hemoglobin count.

Vital signs -BP 170/100, HR 86 bpm, RR 82.50 bpm, SpO2 93% on RA, Weight 84kg, Height 156cm.

NARROW DIAGNOSIS

Hypercholesterinemia

Rheumatoid arthritis

Gastric ulcers

ANALYSIS

Hypercholesteremia is another possible differential diagnosis that results from a diet rich in high cholesterol and alcohol consumption. The patient has a history of taking cholesterol-

reducing drug, which is atorvastatin calcium 20mg. He presents with symptoms of hypercholesteremia, such as peripheral hypertension.

Rheumatoid arthritis; The patient’s past medical history reveals a history of autoimmune rheumatoid arthritis that was never managed properly; moreover, he presents with pain in the joints, back, and muscles, weakness, malaise and is frail.

The patient’s past medical history reveals a possibility of peptic ulcers as a differential diagnosis because he has been on omeprazole dosage before his follow up to the clinic; slight abdominal symptoms suggest peptic ulcer disease as a differential diagnosis.

Other complications that may result from uncontrolled blood pressure include;

Aneurysm of the blood vessels

Heart failure in extreme cases

Metabolic syndromes, e.g., diabetes

End organ failure, e.g., the kidneys

Stroke and dementia

PROBE

The patient needs to consult cardiologists to have other tests that could reveal the hidden heart pathologies from the patients’ past medical history and the current treatment regimen.

The involvement of a nutritionist is recommended to have the patient regulate his dietary cholesterol intake.

Further, the patient is recommended to consult the oncologist as there may be possible malignant growth. Lower back pain could have been attributed to the prostatic enlargement or malignancy of the prostate gland; screening would reveal any of these conditions.

TREATMENT PLAN AND FOLLOW UP

The diagnosis made on this patient was made up of subjective and objective history taking and physical examination from the patient, who was the source of information.

Rx: Continuation on Bystolic 40mg daily

Hydralazine 25 mg twice daily and losartan daily

Omeprazole 20mg daily

Sildenafil 100mg

Atorvastatin calcium 20mg

Reduction on salt consumption

The patient is requested to do a prognostic follow-up to have the vital tests done after two months; further, regular exercise and stress-free living style were advised.

Considering the cost of the medications prescribed, the patient was given options to chose the cheaper drug regimen for his conditions.

SELF- DIRECTED LEARNING

The overall diagnosis of the patient was made in self-confidence. I exhausted the patients presenting signs and symptoms and did a tentative and inclusive history and physical examination.

To arrive at the differential diagnoses, I compared the patient’s past medical history and the history of the presenting illness and posed questions to myself; this helped me find the connection between the past illnesses and the presenting conditions. The patient’s family and socio-economic history were vital in identifying the patient’s current condition’s most probable risk factors (Patel et al., 2017).

During this patient’s clerkship, I shared and discussed the conflicting ideas between the senior nurses in charge and the consultant; this enabled me to arrive at the fine diagnosis.

As a young medic, utilizing the opportunities in making an appropriate diagnosis, making use of the patient-doctor decision making and sharing of ideas while learning different criteria in patient management as some of the essential skills in learning how to properly care for the patients and making prompt diagnosis which ultimately improves the patient’s prognosis up on the administration of appropriate medication. The process of interacting with the patient and getting to the management of the condition has been very educative and important in my career; this has not only made me realize my dream of becoming a wonderful nurse but also boost my confidence and my relationship with people in difficulties through the change of empathetic personality and feeling the sense of sympathy to the patients.