Abstract
A complete and thorough health assessment can help in the correct diagnosis (Dingman, 1941). According to a famous saying “A case well taken is half solved”. A well taken case should include complete description of the patient’s mental, physical and social well being. Mere jotting down of physical signs and symptoms may not give the true picture of a disease. As every patient is a different individual, thorough case taking is required in order to establish the individuality of the patient. Many features of the patients may have a role to play in his or her health, therefore, it is important to analyse the personal habits of the patient along with his history. a well taken history brings about the possibilities of many diseases which may have occurred in the past, luring in the present, or may develop in the future. Thus, a well taken a history may not only help in diagnosing a patient in the present, but may also help in preventing the chances of future adversities (Muhrer, 2014). In other words, a well taken case may act as a prophylactic for a patient having a potential to develop serious disease later on in his life. Good case taking is helpful for patients of all age groups and suffering with any kind of illness (Ghosh & Karunaratne, 2015). A good case taking by the nurses becomes all the more important as they are the first point of contact for the patients. They are the ones who are mostly in direct contact with the patients (Fawcett & Rhynas, 2012).
Age: 28 years
Sex: Female Marital Status: Unmarried
Nationality: Indian American
Presenting Complaint: Pain in the upper gastric region since the last 3 days.
History of Presenting Complaint: The patient was apparently well 3 months back. She gradually developed the complaint of pain in the epigastric region on and off. The pain used to be more severe at night or near bed time. When the pain occurred for the first time, she took an antacid after being recommended by a friend. It worked for her wonderfully. Upon developing the same pain again she repeated the same medicine. With time, she developed the habit of carrying the medicine in her bag and taking it every now and then whenever she had pain. The pain recurred almost every other day. But since the last few days, that is, the last 3 days, the medicines could not bring the pain down. She is feeling uneasy, drinking cold water gives a temporary relief to the uneasiness. The burning sensation in the esophagus has made it difficult for her to work or sleep.
Sensation: Burning pain
Modalities: Aggravation- Night, stooping
Amelioration- Drinking cold water
Concomitants: Sour belching
History of Past Illnesses: The patient had typhoid at the age of 15 for which she was hospitalised for a month. Later, at the age of 23, she developed jaundice. She took traditional Indian medicines for the same and got cured. She never had any other major illness in life till date.
General Health Condition: The patient usually remains healthy, except occasional episodes of constipation. She does not take any regular medications.
Childhood Illnesses: No major childhood illnesses
Accidents or injuries: She met with a road accident and got injured at the age of 9. The accident led to a fracture of the right ulna.
Serious illnesses or chronic illnesses: The patient does not have any serious or chronic illness.
Hospitalizations: The patient was hospitalized at the age of 15 years for a period of 1 month due to typhoid.
Operations: She never underwent any operation/ surgical procedure till date.
Obstetric History: The patient is unmarried. G0P0A0L0
Immunizations: She took all the vaccines as per schedule.
Allergies: No known allergies
Current Medications: No current medications
Family History and Genogram: The patient has a strong family history of CHD or Coronary Heart Disease. Her father, uncle and maternal grandfather are patients of CHD. Right after a surgery for heart disease, her father developed hypertension. On the other hand, her mother, maternal grandfather, and uncle are diabetic.
Review of Systems:
Respiratory System: No dyspnea, no cough, no wheezing. No throat abscess. No pain. No congestion of chest.
Gastrointestinal System: No abnormally visible veins. Bilaterally symmetrical, scaphoid abdomen. No organomegaly. No fluid thrill. Increased bowel movements heard on auscultation.
Genitourinary System: Denied by patient
Musculoskeletal System: No joint pain, swelling, tenderness or redness of any joint. No pain on movement.
Nervous System: No abnormality in gait. Well oriented to time and space. No deficiency of memory. No giddiness.
Cardiovascular System: No palpitation. No congestion. No murmur or arrhythmia.
Functional Health Patterns & Activities of Daily Assessment: The patient is otherwise overall healthy. There have not been much incidences of absence from office due to health reasons. She has a tendency to put on weight very easily. She mostly eats packaged or fast food. She drinks 3-4 litre of water per day.
Self perception/ Self Concept: The patient is quite confident and determined. She has been staying alone in the US since the last 5 years. Being an Indian, she found it difficult to adjust in the US society for the initial few years. But with time, gradually, things fell into place and she settled down in U.S.
Activity/ Exercise: She visits the gym every alternate day. Her work out schedule continues for 1.5 hours. She has been following the same routine since the time she has shifted to the U.S.
Sleep/ Rest: She sleeps for 7 hours at night. Her sleep is usually refreshing; however, she does feel sleepy after lunch in the office.
Nutritional/ Metabolic & Elimination: Her body metabolism gets disturbed very frequently nowadays. She remains constipated for most of the days in a week. The constipation is usually more prevalent after having antacids the previous night.
Role/ Relationship: She is single and lives alone in a rented apartment in the U.S. Her family stays in India. She is survived by her parents and two younger sisters. They had a hard life. Poor economic conditions compelled her to move to the U.S. in search of a job and a good source of income. Being the eldest daughter of family, she had to bear the responsibility of her family. Her father is a retired government employee and mother is a housewife. Both her sisters are students and are not earning yet. Staying alone at the U.S. was difficult for her in the beginning. Entirely different culture and food habits made it difficult for her to survive, but with time, she adjusted herself.
Coping/ Stress Tolerance: She is a very sensitive and an emotional person. In extremely stressful situations she binges on chocolates. They act as stress relievers for her. Listening to music is another factor that often calms her down in stressful conditions.
Personal Habits: She has the habit of double checking the cylinder knob and the lock of the door before leaving home. She has an unusual fear that someone will snatch her purse or her mobile phone while walking on the street. So she holds her purse tightly and always keeps the phone inside. She also avoids talking on the phone while walking on the street.
Environment/ Hazards: She works in a BPO, her job mostly involves working in shifts. This often leads to a disturbed sleep cycle. Her meal timings also vary according to the shifts. As she lives alone and works in shifts, cooking becomes a difficult task. She is mostly dependent on fast food that she grabs from nearby eating joints while coming back from work.
Intimate partner violence: She is involved in a long distance relationship. The relationship has been going through a low phase. Communication issues have crept in due to differences in the time zone.
Occupational Health: Inconsistent working hours are affecting her health to a great extent.
Health Perception/ Health Management: She does not take much care of her health.
Complete Physical Examination
General Survey: The patient is mesomorphic, normal statured female. She has a mole on the right side of her face. She has a tendency to put on weight very easily.
Height: 5.7”
Weight: 65 kg
BMI: 21.6
Blood Pressure: 130/70 mm of Hg
Heart rate: 78/ minute
Pulse rate: 75/ minute
Temperature: Afebrile
Tongue: Clean & Moist
Skin: She has a wheatish complexion with no sign of erythema or any abnormal pigmentation
Hair: Black, smooth hair
Nails: Shiny, smooth nails with no deformity
Head: Normocephalic
Face: Round
Eyes: No blurring of vision, no redness, normal vision, no itching, no watering of eyes.
Ears: Normal hearing, no redness of pinna, no pain.
Nose: No rhinitis, no alteration of sense of smell
Mouth & Throat: Pink gums, no swelling, no pyorrhoea.
Neck: No enlargement of tonsils. No lymphadenopathy
Thorax and Lungs: No lump, no swelling or redness
Neck Vessels: No visible neck vessels
Heart: No palpitation, no murmurs, no restlessness
Abdomen: Scaphoid, non distended.
Peripheral Vascular & Lymphatic: No lymphadenopathy, no engorged vessels
Neurological Examination: No staggering of gait. No giddiness. No weakness of memory
Musculoskeletal Examination: Normal muscle tone. No flaccidity. No loss of power
Nursing Assessment Summary: The patient is a young unmarried Indian female residing in the U.S. alone. Working in shifts has disturbed her biological clock to a great extent. Improper eating habits and disturbed sleep have disturbed her gastrointestinal system. Her symptoms indicate strongly towards GERD or peptic ulcer. The increase in the number of bowel movements and amelioration by antacids further strengthens the diagnosis.
Overall Summary: The provisional diagnosis for the patient is GERD. Amelioration from antacids supports the diagnosis. Furthermore, disturbed pattern of life adds to the aggravating factors for the disease. However, confirmatory tests are required before reaching to the final diagnosis. A thorough examination, including CBC, USG abdomen and stool test are needed (Mayo Clinic Staff, 2016). Some important nursing diagnoses related to GERD are: anxiety, chest pain, imbalanced nutrition and risk of aspiration (Nandahealth.com, 2016).
References
7 Nursing Diagnosis for GERD | Nursing Diagnosis and Nursing Interventions. (2016).Nandahealth.com. Retrieved 31 August 2016, from http://www.nandahealth.com/2015/10/7-nursing-diagnosis-for-gerd.html
Dingman, R. (1941). The importance of case history taking in oral surgery practice. American Journal Of Orthodontics And Oral Surgery, 27(6), A291-A299. http://dx.doi.org/10.1016/s0096-6347(41)90527-6
Fawcett, T. & Rhynas, S. (2012). Taking a patient history: the role of the nurse. Nursing Standard,26(24), 41-46. http://dx.doi.org/10.7748/ns2012.02.26.24.41.c8946
Ghosh, D. & Karunaratne, P. (2015). The importance of good history taking: a case report. J Med Case Reports, 9(1). http://dx.doi.org/10.1186/s13256-015-0559-y
Mayo Clinic Staff,. (2016). GERD Tests and diagnosis - Mayo Clinic. Mayoclinic.org. Retrieved 31 August 2016, from http://www.mayoclinic.org/diseases-conditions/gerd/basics/tests-diagnosis/con-20025201
Muhrer, J. (2014). The importance of the history and physical in diagnosis. The Nurse Practitioner,39(4), 30-35. http://dx.doi.org/10.1097/01.npr.0000444648.20444.e6
