Physical Evaluation Papers Adult Evaluation

Physical Evaluation Papers Adult Evaluation

Identifyng Data

Name: Joshua Michael

Occupation: Mason

Reliability of Historian: Authentic

DOB: October 13, 1949

Source of History: Patient

Age: 48

Sex: Male

Birthplace: Nairobi

Race: African American (Black)

Religion: Catholic

Insruance: MediCare

Subjective Data

Primary Complaint

Patient reported that he is feeling severe abdominal pain from the duration of 3 to 4 months.

Present Health Status

Joshua Michael is a 48 years old man with a past medical history of depression. He is presently complaining about abdominal pain that he says has is bothering him for the last 3 to 4 months.

Current Health Data

The patient is suffering from abdominal pain and has not taken any medication for its cure. He is convinced that the pain is not associated with food or eating and that it may have worsened due to continuous outdoor activity. He also describes a lump in his throat which was later diagnosed as dysphagia.

Family Data

Joshua's mother expired of natural causes at the age of 63. His father's medical records could not be accessed and, therefore, his medical history is unknown. However, the assessors could not find any signs of cancer in the family.

Review of System

Head: Mild headaches, nausea and motion sickness.

Ears: No difficulty in hearing.

Nose: Not assessed in examination.

Throat: Lump in throat found.

Cardiovascular: No chest pain.

Gastrointestinal: Complain of sharp abdominal pain and endorses constipation.

Family History

Legend

History of present illness

The patient is suffering from abdominal pain and has not taken any medication for its cure. He is convinced that the pain is not associated with food or eating and that it may have worsened due to continuous outdoor activity. He also describes a lump in his throat which was later diagnosed as dysphagia.

Past Medical History

The patient has gone through tremendous physical stress. he has a history of back pain and also underwent physiotherapy sessions around three years ago since the pain had become unbearable.

Childhood Illness

In his childhood, the patient contracted malaria twice and was also affected by jaundice. Even though the patient recovered from these illnesses, his health suffered considerably and he lost a lot of weight as a result.

Adult Ilness

Upon entering into adulthood, the patient has mostly complained of back pain which became aggravated around three years ago so that physiotherapy sessions were recommended to help the patient recover.

Past Surgical Histories/Allergies

No previous records have been found that may suggest that the patient underwent any surgical procedures. However, the patient is found to be allergic to tree nuts.

Nursing Process

The nursing process is “an organized systematic and purposeful approach to nursing with the plan of improving standards in nursing care” (Rush, Fergy & Wells, 1996). The process of nursing is a scientific method used by nurses for ensuring the quality of patient care. This approach could be broken down into five critical steps:

Assessment

Diagnosing

Planning

Implementation

Evaluation

Health Assessment

Health evaluation is a vital treatment function that present basis for excellence nursing intervention and care. It facilitates in identification of the force of the clients in encouraging health. It also facilitates to recognize the needs of clients, clinical harms or nursing diagnosis and to assess answer of the person to healthiness complications and interference ...