Identifying Data: R.M.
Reasons for Seeking Health Care
High fever, vomiting, and severe stomach ache.
History of Present Illness
The patient came to the clinic with a complaint of recurrent high fever, vomiting, and stomach aches for the last 6 or 7 months. The high fever often occurs in the night, followed by severe stomach aches, which last for about an hour per episode. Characteristics: When an episode of stomach ache is almost ending, the patient noted that she then vomits for close to five minutes. The client stated that she sometimes experiences up to three episodes per attack. High fever and sweat around the palms, neck, and head, pain in the abdominal region, and nauseating feeling, which results in vomiting. Aggravating factors: These symptoms occur in the night or sometimes in the morning, especially during very dusty weather. Besides, certain meals seem to catalyze the occurrence of these symptoms. Relieving factors: Hot water laced with honey and cinnamon leaves. Treatment: There is no existing history of any treatment apart from over-the-counter painkiller tablets to arrest the fever.
There is no special medication that the patient is currently using to manage this condition apart from self-prescribed painkiller tablets. Besides, R.M. sometimes relies on a cocktail of honey and cinnamon mixed in a glass of hot water to get temporary relief. However, there is no prescribed medication that the patient is using to manage the condition.
The patient is allergic to dust and red meat. There is no evidence of allergy toward any form of medication.
Past Medical History
The patient has had three mild cases of stomach ulcers and indigestion in the last five years. The patient has survived an accident and was treated with neck-related injuries three years ago. As a toddler, the patient was once hospitalized with a mild case of liver complications and was treated with jaundice. The treatment lasted for almost a year. The patient has sunburns from her visit to the tropic region of Southern Brazil in the last three weeks.
Past Surgical History
As a teenager, at the age of 15 years, the patient underwent minor surgery to restructure her jaw bone following a bicycle accident. At the age of 25 years, the patient underwent cosmetic surgery to rearrange her dental formula. The two surgeries were successful and no difficulty was recorded.
There is no major hereditary ailment from both sides of her grandparents who are still alive. The grandparents are managing cases of mild vision impairment due to old age (paternal grandmother), recurrent hypertension (maternal grandmother), temporary disability (paternal grandfather fell and broke his left hand), and lung cancer (maternal grandfather). There is very limited information on their general medical history because of the inability to have health covers, apart from the paternal grandfather who is a retired military veteran. The patient’s father died at the age of 58 years in a plane crash accident. The father’s medical history indicates that he was struggling with depression and a mild case of stomach indigestion. The father survived on antidepressants for the last ten years of his life. The patient’s mother is currently a teacher who has had no noteworthy medical challenges. However, she is allergic to dust and woolen garments. The only existing record of surgical operation involving the patient’s parents or grandparents is the orthopedic surgery to reconstruct the paternal grandfather’s broken hand.
The patient is a social drinker and admits to regularly smoking medical marijuana whenever she feels tense. The patient is a professional ballerina instructor in one of the local schools and runs a home-based physical exercise program. The hobbies of R.M. are vocational traveling and dancing.
Sexual and Reproductive History
The patient’s sexual orientation is heterosexual. The patient lives with her husband who she married ten years ago. The patient has two teenage sons and a toddler daughter.
Health Care Maintenance (HCM)
Being a frequent traveler to tropic regions, R.M. periodically goes for vaccine jabs, especially against Malaria and Yellow Fever. She is a frequent blood donor (after every six months).
Review of Systems
Most of her systems are properly functional. The physical assessment does not give clear data on what could cause high fever and vomiting.
Complete Physical Examination
Pulse 85, temperature 127 f, blood pressure 170/95, weight 129, height 6’8, respiration 21, and body mass index (BMI) 21.
Mental Status Exam (MSE)
The patient is well-groomed, that is, neat clothes, well-kept hair, and adheres to basic standards of hygiene. The patient seems aware of her surroundings and very articulate in expression. This positive cognition is an indication that the patient is normal.
There is no indication to suggest that the patient has any serious behavioral malfunctions. The patient shows genuine concerns over her current condition and has brought herself to the clinic.
The patient seems tense when explaining herself, probably because of the abdominal pain. R.M. has clear thought-response coordination and provides logical answers that are relevant to the questions asked by the specialist.
The patient takes some time before responding to each question with mild speech breaks. The patient is aware of her immediate environment and needs as indicated in the well-coordinated cognitive functionality in encoding and decoding messages.
The mental examination reveals normalcy in the patient’s state of mind because her actions, reaction, and articulation are within the normal range (Judith, Baile, & Docherty, 2011).
R.M. has pale skin, especially on the regions not covered by her attire such as the face, legs, and hands due to sunburns from a recent trip. The skin is pink within the normal range and responds appropriately to the touch. The surface of her skin is warm, smooth, and has enough moisture. The patient’s nails are pink and conform to normal as revealed by the Blanch Test (Robinson, n.d.). The surface of her nail is flat. R.M. has very thick, dark, and long hair with no physical signs of infestation or malnourishment. The observation and test reveal that the patient’s nails, hair, and skin are within the normal range for her age.
The patient has a symmetrical head that is slightly angling forward on the forehead. The head does not have visible contours or any sign of injury. All the lymph nodes located in the region of the head are within the average normalcy range.
The patient has white sclera and clear bulbar conjunctiva. The cornea is smooth with shining and pinkish Palpebral conjunctiva. The patient blinks to motion after two to three seconds. The black pupils dilate and constrict normally and proportional to any movement. The patient has normal visual acuity. These tests reveal that the eyes are normal.
The exterior of the two ear lobes is proportional to compact auricles. The canals are clear with no fluid as revealed by the Otoscopic test (Hornby & Atkins, 2013). The patient has full functionality of the ears as revealed by the Watchtick test (Jones-Smith, 2011).
Nose and Sinuses
The nose is well placed and firm with normal color. There is no aching reaction on palpation.
Mouth and Throat
The lips are well moist and proportional. The tongue is pink, rough-textured, and well-positioned with no inflammatory signs or bad smell.
The muscles supporting the neck are proportional and there is no aching feeling upon head movement. The thyroid gland is invisible upon physical assessment. The posterior and anterior lymph nodes are regular.
Normal movement with effortless and metrical respirations through the nose at about 15-17 inhalations and exhalations per minute. The Supraclavicular lymph nodes are okay.
Cardiovascular and Peripheral Vascular
The pulse rate is normal with no pulsation within aortic areas or signs of varicose. The pressure measurement indicates that the patient is predisposed to high blood pressure.
The abdomen has asymmetrical appendectomy scar with abnormal contours that have blemished color. The peristalsis has visible movements with audible auscultation bruits. No bowel sound recorded though the patient has abnormal loose stool.
The muscle movement is normal to the patient’s female gender. However, the patient has discomfort when stretching the hands and legs.
The patient reacts to different stimuli in a normal manner and is articulate in responding to all questions asked. There is no indication of a momentous mental disability.
Hornby, S., & Atkins, J. (2013). Collaborative care: inter-professional, inter-agency and inter-professional. Oxford: Blackwell Publishing.
Jones-Smith, E. (2011). Theories of counseling and psychotherapy: An integrative approach: an integrative approach. New York, NY: SAGE Publications.
Judith, A., Baile, E., & Docherty, S. (2011). Nursing roles and strategies in end-of-life decision making in acute care: A systematic review of the literature. Nursing Research and Practice, 2(5), 45-67.
Robinson, M. (n.d.). . Web.