Running Head: HISTORY TAKING AND PHYSICAL EXAMINATION
HISTORY TAKING AND PHYSICAL EXAMINATION 5
SNAPPS History Taking and Physical Examination
CC
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...
My point of interest was to find out the
disease of old age, which includes hypertension, osteoporosis, benign prostate hyperplasia, and diabetes ketoacidosis, to the moderately to chronic drinkers like the patient I chose. This exposure further led me to learn a few symptoms that are quite often omitted but are a leading route to making these diagnoses.
Recent studies in the health care sector have shown some medical conditions that affect patients with advanced age due to immunosuppression that comes with old age. However, much of these conditions are attributed to affluent lifestyles and the inability to subject the body to sufficient and regular exercise (Sarkar et al., 2019). Antibiotic sensitivity testing has helped make treatment plans for aged patients. Much care has been taken to boost their immune system, especially with the emergence of the bothersome COVID-19 pandemic. Designing the gold standard of treatment for these patients requires proper history taking and physical…
