Individual Client Health History and Examination

Individual Client Health History and Examination



Past Health Review

The patient has multiple health related issues. She has osteoporoses, obesity and her uterus has been removed due to the presence of multiple cysts. She has cardiac issues too with asthma.

Physical Examination

The lower abdomen was pressed hard during acute pain. The patient has acute to chronic pain at one side of her lower abdomen and at the back. She suffers irritation during urination. The urine that is produced is in small amounts and has a yellowish orange color. The urine is said to have an unusual odor.

S

B

A

R

Situation

Clients/ patient initial: ZYSex: FAge: 54

Occupation of Client/ patient: Retired

Marital status: Married

18th April 2013

Health History/ Review of symptoms: Multiple health issues; obesity, hypertension, osteoporoses, Cardiac issues

Complete assessment of health: ZY is a cardiac patient with obesity issue; she is a patient of hypertension for the past 5 yrs.

Background

History of Patient

Cardiac issues accompanied with obesity. Hyper tension and Asthma. Had a Uterus removal surgery

Assessment

The patient was carefully examined both during the pain and at normal condition. Examination of urine was made in terms of quantity and quality produced (Smith, n.d). Musty odor, yellowish-orange urine was observed that showed the initial symptoms of the improper functioning of urine tract system. The body temperature raises up to 101o F. accompanied by severe chills like shivers. Acute pain develops at one side of the waist and back. The skin goes pale with mouth dry. External Urethra and urine output was assessed. Burning and the pain were experienced at the urethral orifice. During urination, the patient had an excruciating pain with a burning sensation. Frequent but a small amount of urine output was observed with slight odor in it. The excessive pain occurred at the lower abdomen of the patient (Balentine, 2013).

Recommendation

Since the ...