Biodata
Name: Angie Dawson
Address: Jacksonville, FL
Marital Status: Married
Date of Birth: 7th of July, 1956
Occupation: High School Teacher
Age: 61
Gender: Female
Race: African-American
Place of Birth: Jacksonville, FL
Mrs. Angie Dawson is a 61-year-old married woman who stays with her husband in Jacksonville. She has two children and three grandchildren – all of them stay away from Mr. and Mrs. Dawson. Despite being 61 years of age, she still teaches at a local high school every weekday. She rarely carries school work to home or on weekends thus spending most of her time outside of school with her husband.
Source of History: Mrs. Dawson. She seems reliable.
Reason for seeking healthcare: Routine clinic for check-up and refill for hypertensive patients on care
History of Presenting Illness: Mrs. Dawson was due for her routine clinic for hypertension – a condition she was diagnosed with five years ago. There is thus no presenting illness. However, Mrs. Dawson complains of early fatigability in recent times and occasional pain in her left knee and both her ankles. She has been on treatment for osteoarthritis before.
Past Health History
Childhood Illnesses: Mrs. Dawson reports that she suffered chicken pox at 6 years of age and had to be admitted for the same. She also says she suffered pneumonia and other acute respiratory tract infections as a child. However, these latter problems did not require hospital admission.
Accidents and Injuries: Mrs. Dawson has not been involved in any disabling or life-threatening accidents. However, she reports that she suffered a thigh injury while playing basketball in high school; the injury did not require admission. She also reports that she has suffered other minor injuries while doing house chores.
Chronic Illnesses: Apart from hypertension, Mrs. Dawson has been diagnosed with osteoarthritis before. She, however, denies awareness of any other chronic illnesses.
Hospitalizations:
- November 1962 – for chicken pox while she was aged six. She stayed at Hospital for nine days before she was discharged on medications she cannot recall.
- March 1981 – she was hospitalized for 2 days for the birth of her son. She delivered via simple vertex delivery after a labor process she terms as normal. She did not have any problems in the puerperium.
- October 1984 – she was admitted for 4 days following a second-trimester miscarriage. She underwent dilation and curettage for the same reason. She was not transfused and was discharged on analgesics, antibiotics, and hematinics.
- January 1987 – she was hospitalized for 2 days for the birth of her son. She delivered via simple vertex delivery after a labor process she terms as normal. She did not have any problems in the puerperium.
Immunizations: Mrs. Dawson reports that she underwent all childhood immunizations as the schedule of that period required. She was vaccinated for influenza 6 years ago when an outbreak was reported in the neighborhood.
Food and drug allergies: She has no known food or drug allergies
Current Medications: Enalapril 5 mg once daily and hydrochlorothiazide 25 mg twice daily.
Surgical History: Mrs. Dawson reports that she has not undergone any other surgical procedures apart from the dilation and curettage she underwent following miscarriage in 1984.
Family History
Angie Dawson was born as a second born in a family of 4. She was the only daughter in the family. Her mother died in an automobile accident in 2008. Her father, who was hypertensive, died of congestive heart failure in 1997. Her elder sister is deceased, she died of throat cancer. Her other siblings are alive and well and so are her two children and all her grandchildren. Mrs. Dawson denies any history of HIV/AIDS, tuberculosis, sickle cell disease, blood disorders or mental illnesses in her family.
Review of Systems
General Health: Mrs. Dawson reports that she has always kept her weight in check but has noticed a slight weight gain in recent times. She denies experiencing fever, chills, sweats, night sweats, fatigue, weakness or malaise.
Skin: Mrs. Dawson soft soap for bathing. She has not experienced any allergies or reactions to changes in soap or body oil. She had acne as a teenager but it ended and has no worries about her current facial appearance. She says that she has a birthmark, a hypopigmented area, on her upper back. She denies any recent skin lesions, hair loss or nail disease.
Head: she reports that she has frequent mild headaches and occasional light-headedness. She, however, denies felling dizzy, seizing or suffering syncopal attacks before.
Eyes: The client says she has good visual acuity when using her spectacles. She was diagnosed with presbyopia five years ago. She, however, denies night blindness, blurred vision, watering of eyes, eye pain or swelling, and redness of eyes.
Ears: She says she has good hearing. She denies any recent ear infections, ear discharge, tinnitus, and vertigo.
Nose: Mrs. Dawson reports occasional colds especially in the winter and fall. She denies nasal discharge or sinus pain. She, however, reports that she had occasional epistaxis as a child.
Mouth and throat: Client reports that she routinely brushes her teeth twice a day and has never had her teeth cleaned. She has never undergone a dental procedure. She complains of a dry cough for the last couple of years. She denies having oral sores, sore throat, bleeding gums, sore throat, dysphagia or toothache.
Neck: she denies having neck pain, limitation in range of movement, lumps or swellings.
Breast: Client performs a self-breast exam. She denies having noticed swellings, lumps, pain, nipple discharge, rash or lumps in the axillary region.
Respiratory system: Apart from the dry cough, the client denies experiencing pleuritic chest pain, exertional dyspnea or recent respiratory infections. She reports having occasional colds in winter and fall.
Cardiovascular system: Apart from her recent easy fatigability, Mrs. Dawson denies dyspnea, orthopnea, cyanosis, pallor, edema, nocturia or chest pain. She has a family history of congestive cardiac failure. She drinks two standard cans of beer every week and does not smoke.
Peripheral Blood Vessels: Client denies any leg pains, skin changes, limb swelling or lymph node enlargement.
Urinary System: She reports that her urine is yellow in color. She denies nocturia, polyuria, dysuria, urinary urgency, oliguria, hematuria, incontinence or lower abdominal and flanks pain. She has no past history of urinary tract diseases or infections.
Gastrointestinal System: Client says she has a good appetite and has at least three meals each day. She normally has one bowel movement each day. She has never had chronic gastrointestinal, hepatic or gallbladder diseases.
Genitalia: She reports no supra-pubic pain, per vaginal discharge or bleeding. She denies having any sores or lesions in the genital area or dyspareunia. She used an intrauterine device for contraception between October 1989 and February 2001.She was screened for cervical cancer in June 2014 by a pap smear; the result was negative.
Sexual Health: She is monogamous and believes that her husband is too. She denies past exposure to STDs or HIV.
Musculoskeletal system: She reports occasional ankle and knee pain. The pains are more with exertion and in the mornings. She has no family history of gout and denies myalgia, back pain or gait problems. She can walk normally.
Neurologic system: She denies any past head injuries, tremors, weakness, incoordination, numbness and tingling, dysarthria or a history of neurologic diseases like meningitis, encephalitis, and stroke.
Hematologic system: She denies having a bleeding tendency, excessive bleeding, lymphadenopathy, radiation exposure or blood transfusion.
Endocrine system: She reports that she has not had any thyroid disease, nervousness, change in appetite or changes in bowel movements.
Functional Assessment
Self-concept: The client is a holder of a bachelor of education degree and works as a teacher in a local high school.
Activities: She does household chores including cooking and washing. She exercises for 30 minutes every day. She, however, drives to work and to shopping
Sleep: She does not use sleep aids. Her resting times are variable but she sleeps by midnight and is awake by 7:00 am.
Nutrition: 24-hour recall – yesterday, she had white coffee with b read and groundnuts for breakfast. She took an orange in mid-morning hours. She took rice, vegetables, and pork for lunch and took pizza for supper. She does not salt her food but she occasionally eats salted food when she eats in restaurants on weekends. She also strives to reduce the amount of oil and carbohydrates that she consumes
Interpersonal Relationships: She lives with her husband. They have a good relationship and spend leisure and weekends together. They are visited by their children twice each year.
Coping and Stress Management: She copes with stress normally by communication and relaxation.
Drug use: Mrs. Dawson has never smoked actively. She takes two standard cans of beer every week. By CAGE analysis, she is not addicted to alcohol (Glynn et al., 2012). Occasionally takes over-the-counter analgesics.
Home Environment: Her home environment is safe by federal standards. The house is 16 years old.
Occupational Health: She is not exposed to loud noise or noxious substances in her line of duty
Motor Vehicle Safety: She rarely uses seatbelts. Both she and her husband drive at acceptable speeds.
Spiritual Health: She is a theist who occasionally attends a Baptist church.
Health promotion: She has a personal primary care physician who last examined her in April 2017. She has no primary care dentist.
Perception of Health
Mrs. Dawson states that she understands the importance of good health, good nutrition, and exercise. She also admits that she does not exercise enough.
Physical Examination
Date: August 30th, 2017
Height: 1.7 meters
Weight: 83 kg
Blood Pressure: 123/81 on the arm
Temperature: 37.1° Celsius
Radial pulse: 78 beats per minute and regular
Respiratory Rate: 19 unlabored
General Survey: Mrs. Dawson looks happy and cheerful. She looks like a person of the stated age and gender. She is logical and coherent in speech and has her memory intact. She maintains eye contact and is cooperative in history-taking and physical examination. She has normal gait and has no involuntary body movements. On standing up, she has no visible lordosis or kyphosis.
Skin, hair and nails: Mrs. Dawson appears clean and well kept; her skin is smooth and pliable and has normal pigmentation. She has hair on the head and in the armpits with no evidence of alopecia. She has no tattoos. Her nails show leuconychia or koilonychia.
Head: Her face is symmetric and she has no masses, scars or regions of tenderness
Eyes: Visual acuity of 20/20 by Snellen chart. She has normal visual fields with a symmetrically bilateral consensual light reflex. She has eye brows and eye lashes. Her conjunctiva is mildly red. On fundoscopy – there are no lesions, there is a bilateral red reflex, and normal blood vessels appear in all quadrants.
Ears: The pinna appears normal and the external auditory canal is clear. The tympanic membrane appears gray and is intact; it has a normal light reflex too. She can hear whispered words well in both ears. Both Weber’s and Rhine’s tests were normal.
Nose: Both nares are patent and reveal a pinkish mucosa. No discharge or lesions are seen. There is no tenderness around the sinuses on palpation.
Mouth: She can clench her teeth without a problem. The mucosa and the teeth appear normal and there are no lesions. The tongue is smooth, pink, and protrudes in the midline. The tongue can be folded and moved from side to side. The temporomandibular joint can be moved without difficulty, pain, or crepitus. The gag reflex is present. She smiles and frowns symmetrically and without difficulty. As such, all her cranial nerves are intact.
Throat: The mucosa is pink and normal. The uvula rises in the midline on phonation and the tonsils are not visible.
Neck: The trachea is in the midline. No areas of swelling or tenderness. The neck has a full range of movement and there is no carotid bruit on auscultation bilaterally. She also has normal shoulder strength indicating an intact spinal accessory nerve (Glynn et al., 2012).
Back and Spine: Client has normal curvature of the spine. She has a hypopigmented area on the upper back but the rest of the back has no lesions on regions of tenderness. She also exhibits a full range of spinal movements.
Thorax and lungs: She has symmetric bilateral chest expansion with respiration. There are no areas of tenderness or masses. The anteroposterior diameter of her chest is greater than the transverse diameter and she has bilaterally equal tactile fremitus. On percussion, she has a resonant note over the lung fields and has vesicular and equal breath sounds on percussion.
Heart: The client’s precordium is still with no heaves or thrills on palpation. An apex beat was palpated in the fifth intercostals space mid-clavicular line and normal first and second heart sounds auscultated. Extra heart sounds and murmurs were absent.
Abdomen: The abdomen is flat and symmetric and moves with respiration. There are visible striae on the abdomen. Normal bowel sounds were present but vascular bruits were absent. The abdomen has a tympanic percussion note and has no masses or detectable organomegaly on palpation. There are no areas of tenderness or rebound tenderness and both Murphy’s and Blumberg signs are negative.
Extremities: Both arms and legs are symmetrical and exhibit their full range of movement. All peripheral pulses were palpable and were equal bilaterally. The capillary refill was two seconds. Finger clubbing, edema, cyanosis, and varicosities were all absent. Negative Homan’s sign bilaterally.
Neurologic: All cranial nerves and higher functions of the client were normal as seen in the literature above. The client had a normal gait and could walk without difficulties; she also had a negative Romberg’s sign. Rapid alternating movements and finger-to-nose movements were all intact. She also had normal abdominal reflexes, a normal Babinski’s reflex, and normal deep tendon reflexes bilaterally.
Assessment Findings
Pertinent Positives:
- 61-year old Female
- Known hypertensive patient
- Previous diagnosis of osteoarthritis with occasional knee and ankle pain
- Easy fatigability
- She takes acceptable amounts of alcohol and is not an addict
- Family history of congestive heart failure
- High Body-Mass Index
- Reduced salt intake
- Frequent headaches
- Hypopigmented area in her upper back
- Regular exercise
Pertinent Negatives:
- No known food or drug allergies
- No significant past medical or surgical history
- Does not smoke
- No cough
- No orthopnea
- No dyspnea
- No extra heart sounds or murmurs
- No blurred vision
- No lesions were seen on the optic disc on fundoscopy
- No history of thyroid disease or diabetes
- No carotid or renal artery bruits
- No abdominal organomegaly
Plan and Intervention
Based on the assessment, Mrs. Dawson’s blood pressure is well controlled and she has not developed any complications of hypertension like heart failure, encephalopathy, nephropathy, and retinopathy (Lewis et al., 2014). However, it is important for her to have her osteoarthritis managed. I could thus advise her to continue using her current antihypertensive regimen, to continue avoiding salt, and to check on her weight. She also needs to exercise more in order to reduce her weight (Bickley et al., 2013). However, she should take precaution not to overstrain her joints while exercising. She needs to see her primary care physician, a rheumatology specialist, or an orthopedic surgeon to address her joint problem.
References
Bickley, L. S., Szilagyi, P. G., & Bates, B. (2013). Bates’ guide to physical examination and history-taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Glynn, M., Drake, W. M., & Hutchison, R. (2012). Hutchison’s clinical methods: An integrated approach to clinical practice. Edinburgh: Saunders/Elsevier.
Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & In Harding, M. (2014). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis, Missouri: Elsevier, Inc.
