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Health Assessment and Physical Examination, Case Study Example

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Case Study

Introduction

Patient Assessment is vital part of nursing care with nurses’ roles in primary care setting having to  expand in order to meet the demand of the rapid changes of NHS. Physical examination become part of some nurses roles, as medical institutions strive  to improve patients’ experience and enhance service quality among the population.

As a practice nurse working in the General Practice, the author’s role is expanding, in that performing health assessment and carrying out physical examination has become an integral part of the job description. Practice nurses assume a significant expanded role in meeting the health needs of the primary health care, and as such the role of undertaking physical assessment can significantly facilitate and enhance the care of patients.

In this essay the author is going to discuss and analyse a case study of a patient who visited her clinic in relation to the health assessment and physical examination she carried out during a consultation. The author will demonstrate how a Patient Centred Approach should be used to ensure that this particular patient needs were adequately met. A pseudonym is used for the patient in order to maintain confidentiality (NMC 2008).

Discussions concerning how the condition was diagnosed using the appropriate models of care as guides for history taking and physical examination process,  and possible differential diagnoses will be done. Implication of physical and psychology related to the diagnosed condition will also be presented. Additionally, author will also critically analyse the current research underpinning this condition and what impact they can make on the management of the patient.

Medical and Nursing Models will be applied in relation to the Assessment and Care that has been given to this patient. The related theories of research and epidemiology related to the condition will be inculcated. Medical model uses measurable and technology to achieve diagnoses objectively, with symptoms of the patient being prioritised so that the assessment can become more narrowed and pure medically, despite the overlooking of the patient mind-body needs.

Finally, the Nursing Model was included in the process, due to the argument by Roper, Logan & Tierney (1996) that it will help as a vital source of guidance in the assessment of the case study being undertaken.

Case History

Mavis is a 55-year-old female was seen by her GP due to a chest infection, she was given a course of antibiotic and she was advised to return to the surgery for a follow up. Although she completed her prescribed treatment, she was still complaining of shortness of breath and chest tightness.

Patients often find that the clinical setting stokes up anxiety because according to Sparks Ralph & Taylor (2007), anxiety commonly results from a lack of trust in the environment, and can be reduced by identifying and removing as much as possible, the environmental stressors. In order to alleviate the stress prevailing during the assessment, Mavis’s chair was arranged close to the author’s seat in order to create a more relaxing and welcoming environment.

Data Gathering

Shah (2005) suggested that various communication techniques are essential in order to be able to gather data effectively, and uses of open questions can be helpful in identifying the reason for a patient’s attendance, while Sparks Ralph & Taylors (2007) reports that a well defined database should begin with admission signs and symptoms, chief complain, or medical diagnosis.

Historically, Mavis has been having symptoms of shortness of breath and chest tightening for over five years with little or no variations in her symptoms, but she tends to feel worse in the morning and in cold, damp or windy conditions. However, the timing of her breathlessness symptoms can be indicative of several possible causes.

Critically speaking, exercise-induced cough suggests exercise-induced asthma and coughing at night might suggest asthma or cardiovascular disease. However, despite the commonly held belief that shortness of breath and coughs are common symptoms of respiratory disease, it can also be indication of other system disorders, therefore, red flag symptoms and other differential diagnosis need to be considered such as GERD, CCF, PE, TB or Cancer, among others.

Differential Diagnosis, according to Scott Richardson, Wilson, Lijmer, Guyalt & Cook (2002), entails finding the evidence, determining whether the results are valid, deciding what constitute the results, evaluating whether these results can be applied to patient care, and making clinical resolutions.

In Mavis case it was vital, that differential diagnosis be seriously considered and applied, as the process ensure misdiagnoses are minimized, especially through thorough history taking, as it was suggested that 90% of diagnosed can be made by this approach.

However, breathlessness on exertion is not always indicative of disease because normal persons may feel short of breath with strenuous exercise, and any level of activity tolerated by any individual depends largely on the incumbent’s age, sex, body weight, physical conditioning, attitude, and emotional motivation.

Mavis described that there have been no attacks of breathlessness at rest but she wheezes and feel tight chested from time to time particularly on first emerging into the cold. Historically, her feeling of shortness of breath had not become apparent until she started taking up walking as she was inactive before she was made redundant as a supermarket cashier.

Enquiry of Mavis severity of her breathlessness, and whether it is continuous or intermittent and timing of her breathlessness will be crucial in identifying whether differential diagnosis between asthma, chronic obstructive pulmonary disease (COPD) or pulmonary oedema, as she was reported to have coughs up grey sputum most morning for many years, though no haemoptysis.

Colour and presence of blood in the sputum is also suggestive of a number of diseases and it is also important to elicit the red flag symptoms. She described simple cough can go to her chest and her sputum turn green and it takes almost three weeks for her chest to become better again after antibiotic treatments. For the past two years, she suffers at least three chest infections per year.

There are often unselected and undifferentiated clinical problems seen in the general practice, therefore, the ability to take an accurate medical history from patients is one of the core clinical skills that clinicians need to possess. Furthermore, integration of clinical and communication skills would enable clinicians to understand the patients’ symptoms and physical signs as well as other important factors, such as the impact of a medical problem on their lives, health beliefs, worries and expectations about diagnoses and treatment.

Red Flags conditions, according to Holistic Anatomy (2011) are conditions therapist and healers should be aware of and use as a basis for immediate reference to physicians, as without it many patients would often be referenced unnecessarily and perhaps costly after certain observations during medical checkups, as means of prevention.

Identifying and interpreting red flags are an important part of clinical practice, as they can be a prediction of more serious or life threatening underlying conditions. Therefore, symptoms such as chest pain, fever or sweats, weight loss, haemoptysis were excluded during taking Mavis history.

Information of past medical history and family may aid in strengthen a suspect diagnosis, such as coronary artery disease or respiratory disease in the same family may indicate prevalence.  However, Mavis did not have any previous medical history, there were no drug allergy history although her father was a heavy smoker and suffered from emphysema and he died of lung cancer 10 years ago.  Retrospectively, this event may have impacted Mavis avoidance of seeking medical advice, despite  5 years history of experiencing shortness of breath.

Mavis was not found to be taking any medication or over the counter medicine including hormonal replacement therapy. This was significant as some medication such as non-steroidal anti-inflammatory drugs, beta-blockers were commonly associate with respiratory problems, and should be included as part of any patient historical records.

There was no historical information regarding her travelling and as such there were no need for quarantine, which would become necessary if patients had returned from any areas of the world where malaria and tuberculosis were endemic.  However, this was not necessary to go into detail as Mavis has not been travelling recently and no history suggestive of contact with any tuberculosis individual.

Mavis Smoking and Alcohol Historical Issues

Patient’s social history information such as smoking history and alcohol intake is sought because of the strong evidence link between tobacco and coronary artery and respiratory diseases and both disease chief compliant can consist of shortness of breath.

The fact is supported by the American Heart Association 1992 published literature report which showed that the risk of death due to heart disease increased by about 30 % among those exposed to tobacco environment at home, and would be much higher if workplaces were similarly exposed to the same high levels of ETS, according to  Steen land, Thun, Lally, & Heath (1996).

Similarly, the World Heart Foundation reports that smoking increases the risk of coronary heart disease in men and women. The organization went further to say that several epidemiological studies have demonstrated that an almost linear relationship existed between smoking and coronary heart morbidity and  mortality, and the risk was more than two fold in and most pronounced in younger adults (World Heart Foundation, 2011).

Mavis is a life teetotaller, however she admitted that she smokes an average of 20 cigarettes per day for 35 years, it is estimated that she has a smoking history of 35 pack-years (BTS 1997). Indeed each symptoms of the patient complaint with should prompt a series of specific questions that would help in arriving at a preliminary single diagnosis.

According to Stave et al (2005), the quantity of cigarettes that a patient smokes is probably  the single most  information that can be obtained  to aid in the proper diagnosis of the patient. To Mavis credit in this case, she had recently cut down to smoking 10 cigarettes per day as she experiences the increased shortness of breath.

She strongly believes that her present symptoms were due to her smoking and  is apprehensive of having lung cancer liked her father. However, Mavis finds it difficult to give up smoking all together due to boredom as she lives alone after splitting up with her partner five years ago.

Patient Work History

The increase in workloads of the past decade according to Murphy (1996), has led to the number of employees experiencing psychological problems related to occupational stress increasing rapidly in Western Countries. At the individual level, according to Turluin (1994), the costs are high rates of tension, anger, depressed mood, mental fatigue and deep disturbance. Turluin (1994) further cites that that aggregate of these problems is referred to as distress but is also classified in other arenas as neurasthenia, adjustment disorder or blowout.

In regards to Mavis, she was made redundant as a supermarket cashier recently, when Inquiry of her occupation and home circumstances were done to  ascertain whether stress was a contributing factor aggravating her shortness of breath symptoms , due to the strong link between anxiety and shortness of breath.  Moreover, although her shortness of breath and cough worsen in the morning, her symptoms improve soon after she has her first cigarette in the morning. Her strongest fear is that as soon as her father gave up smoking he was diagnosed to have lung cancer, which made a vast impact on her psychologically about giving up smoking.

Attitudes and Beliefs

In order to perform a competent, relevant, and thorough assessment of  patient, cultural issues according to Tseng & Streltzer (2008), must be taken into consideration, because cultural factors affects all the components of clinical assessment, namely observation of the patient, history taking, physical examination and laboratory testing.

Tseng & Streltzer (2008), also noted that cultural issues are most obvious when the patient have different background from the health care provider, and may have different beliefs and understandings regarding the particular sickness being investigated. Patients the writers further argued , symptoms and complaints to a given condition may be related differently, and their attitude about being examined and tested are likely to also vary substantially.

Knowing the patient’s attitude and beliefs therefore, can  be helpful in reducing the misunderstanding  patients may have of the cause of their symptoms in a patient focused approached.  This process will help to remove unjustified fears due to the culturally tailor made information package that are given to increase the level of reassurance. In addition the approach will also aid in the achievement of realistic management and treatment goals.

With respect to Mavis, she seemed more  relaxed as the consultation progressed, due possible to the  health provider maintaining good eye contact and relaxed open posture. This approach it was hoped would give her time to answer the open ended questions, as she would be less likely to be negatively affected by the presence of anxiety which can bring on the breathlessness she often experienced in other unfavourable environments.

Physical Examinations

When the physical assessment phase of the assessment began, it was  noted that Mavis became slightly breathless and this was possible may be due to the time she spent walking  up the stairs before coming into the consultation room. There were no signs of cyanosis, or oedema of her extremities. Although Mavis was breathlessness, she seemed comfortable and not appeared to be in distress.

On examination Mavis was apyrexial, raised of body temperature could be indication of infection, she did not show any signs of shock her pulse rate of 80/min, blood pressure of 125/80 mmHg, and respiratory rate of 17/min. her oxygen saturations on air were 98%.  Her height 165cm and weight 59kg which made her body mass index 24 kgm². Her peak flow was 280L/min which is 75% predicted value. She has no evidence of weight loss as it can be caused by malignancy, chronic infection such as tuberculosis or HIV, COPD or heart failure. There was no evidence of peripheral oedema that might be suggestive of congestive cardiac failure.

Though, Mavis’ finger nails have no signs of clubbing, her nails are yellow stained which indicative of her being a heavy smoker.  Evaluation of cigarette stains as a marker of tobacco related diseases, the development of stains independent of the cumulative exposure to smoking.

Careful examination of the fingernails can provide clues to underlying systemic diseases, clubbing, which is one example of a nail manifestation of systemic disease, such as inflammatory bowel disease, pulmonary malignancy, asbestosis, chronic bronchitis, COPD, cirrhosis, congenital heart disease, endocarditis. Mavis’s conjunctiva and mucosa areas are pink, as pallor of conjunctivae, nail beds, palmer creases and face may indicate anaemia in which can cause symptoms of shortness of breath.

On inspection of Mavis neck and chest area, there was no tracheal deviation or asymmetry of chest shape, as abnormality could be an indication of pneumothorax, pleural effusion, and abnormality of chest shape such as kyphosis or scoliosis can affect breathing capacity. There no complaint of tenderness on palpation of the ribs and sternum. Chest expansion symmetrical, however, there was slight bilateral decreased in chest expansion.

According to Ford et al. (2005), the observing chest movement is vitally important if one is to  make a more accurate assessment, since bilateral decreased chest expansion can be more difficult to detect, as is often seen in asthma and COPD.

 

The use of an algorithm which consist of a diagnosis, suggestive, and unexplained component along with careful on history and physical examination at the core, according to American Family Physicians(1998), will provide a diagnostic framework for the evaluation of lymphadenopathy.

According to American Family Physicians (1998), generalized patients with lymphadenopathy, can by physical examination with a strong focus on finding signs of systemic illness be detected, and most helpful findings are rash, mucous membrane lesions, hepatomegaly, splenomegaly or arthritis.

In the case of Mavis,  no cervical lymphadenopathy was found, as positive findings may be associated with lung pathology. However it needs to be assessed with associate symptoms such as night sweats, weight loss and persistent fever.

There was slight diffuse hyper-resonant, which can be indication of pneumothorax or COPD, but other symptoms and history has to be drafted in to the process to  help in guidance of the right diagnosis. On auscultation it revealed there was reduced breath sound on both sides of Mavis chest. No adventious sounds heard.

Differential Diagnosis and Red Flag Symptoms

No chest pain, no haemoptysis, no night sweat, no fever, no chest pain, no increased respiratory rate and pulse rate (which could indicate signs of shocks) therefore excluded red flags such as pulmonary embolism, TB, pneumothorax.

Mavis was excluded from the possible underlying cardiac symptoms, such as chest pain, normal blood pressure, no extremities oedematous.

The patient breathlessness and cough is no worse at night nor when lying down, which could be symptoms of congested cardiac failure or gastroesophageal reflux disorder.

Due to her smoking history and symptoms, it could be suggestive of chronic obstructive pulmonary disease (COPD). However many patients with COPD were wrongly diagnosed with asthma, therefore, a combination of history taking and physical examination with diagnostic test such as chest x ray and lung function test was organised for Mavis, for further investigation and to  exclude any differential diagnoses.

NICE COPD Guidelines

The NICE COPD guideline  according to British Columbia Medical Association (2010), recommends that diagnosis of COPD should be considered for people who are over 35 years of age, who are smokers or ex-smokers and have exertional breathlessness, chronic cough, regular sputum production, frequent winter bronchitis or wheeze. These characteristics were consistent with Mavis demographic and clinical picture.

However, differential diagnosis needs to be considered and relate to her other risk factors, because smoking increases the  chance of cardio-vascular disease, according to the Interheart Study (BCMA, 2011), and it was also important to point out that differential diagnosis of asthma, as treatment and management may be different.

In retrospect, medical examinations may not be useful in distinguishing between Asthma and COPD,  as it also can provide information of other differential diagnoses.

Diagnosis by Spirometry Test

Chronic Obstructive Pulmonary Disease  (COPD), as a result of  Patient Assessment and  limited Clinical Examinations are under-diagnosed according to BCMA (2011). The issue should be addressed by organizations complementing the use of Spirometry Testing  with their traditional methodological approach.

According to BCMA (2011), clinical judgement should be used to select patients for the Spirometry Testing, and those that are selected should be characterize by being smokers or ex-smokers, be at least forty years of age or more,  have been identified with persistent cough, being diagnosed severe respiratory infections, and have complained on examination of having shortness of breath that seems unexplainable.

In a cautionary move, BCMA (2011),  has pointed out that patients should be subjected to X-Ray to confirm the necessity of Spirometry testing as some patients may develop COPD without being tobacco users, as well as that fact that other risk factors may come from occupational exposures, early childhood lung infections, exposure to lung infections especially in areas where wood burning prevails, as well as the presence of alpha 1-antitrypsin deficiency among patients.

Additionally. the organization COPD and Asthma can coexist, and medical facilities should be aware during patient assessment that in office spirometry testing requires the approval by the College of Physicians and Surgeons Diagnostic Accreditation Program before beginning its use (BCMA, 2011).

Asthma and its Symptoms

Asthma, according to the Michigan Department of Community Health (2005), is a chronic condition in the lungs. It has two major components when affecting its victims and these are the tightening of the muscles surrounding the airwaves and the inflammation, swelling and irritating of these airwaves.

Constriction and inflammation of the airways according to the  Michigan Department of Community Health (2005), causes the narrowing of the airwaves and the production of symptoms such as wheezing, coughing, chest tightness or the shortness of breath.

The disease the Michigan Department of Community Health (2005), reports cannot be cured, but can be controlled through carefully controlled disease management programs, which will prevent the long term loss of lung functions which can occur if it is left untreated over an extended period of time.

Accurate assessment of asthma symptoms is critical in research and clinical settings , according to Wood, Smith, O’Donnell, Galbreath, Lara, Forkner & Peters (2007), and a multi-dimensional asthma control  questionnaire could provide  more accurate information on its symptoms than what are provided from global assessment related organizations.

Management of Chronic Obstructive Pulmonary Disease (COPD)

The disease COPD is a respiratory disorder that is largely that is largely caused by smoking, and is characterized by progressive, partially reversible airway obstruction and lung hyperinflation, systemic manifestation and increasing frequency and severity of exacerbations, according to Respiratory Review Panel (2007).

COPD however,  according to BCMA (2011), can be managed by implementing care objectives, emphasizing lifestyle management, instituting pharmacologic management procedures, maintaining ongoing care, developing and communicating exacerbation plans, managing morbidity, providing indications on referrals for specialists, and monitoring and maintaining end of life care.

In exercising care objectives, physicians according to BCMA (2011), should be encouraged to identify new patients using spirometry testing, monitor key clinical indicators using a flow chart, use reliable recall systems  to ensure patients are seen at appropriate intervals, constantly review patients records to ensure they are seen regularly and constantly consider the possible existence of co-morbidities among patients.

Therapeutically, organizations responsible for managing the goals relating to COPD, should develop programs  and strategies to prevent the progression of the disease, alleviate breathlessness and respiratory symptoms, improve exercise tolerance and daily activity, reduce mortality, improve health care status, and treat exacerbations and complications associated with the disease ( Respiratory Review Panel, 2007).

A critical aspect of life style management, according to Respiratory Review Panel (2007), is smoking cessation and effective strategies like nicotine replacement therapy and pharmacotherapy are useful for the achievement of long term results, although there are concerns that the latter may have significant side effects in some patients.

Physicians can play key roles in education and self management among COPD patients, should they constantly help to reinforce the smoking cessations program, encourage exercising, refer smokers with COPD to BC Smokers’ and other Helpline, help  patients identify resources and support, refer patients to pulmonary rehabilitation programs, and advising them to remain indoors when there signs that the environmental air quality index are very low.

A drawback in the management program for COPD was in respect to the Pharmacologic aspect in which Bronchodilators are the mainstay of the program. These equipment according to BCMA (2011), has not provided empirical evidence that they can effectively reverse, slow or prevent the progressive decline in lung function, despite its accomplishment of improving symptoms, reducing exacerbations and hospitalizations, and improving the quality of life of millions of patients suffering from the mainly tobacco based disease.

However, the implementation of these other major strategies, as well as the careful and strategic  incorporation of the pharmacologic management programme in particular, ongoing care treatment, managing of co-morbidities, providing indications for specialists referrals, and end of life care to a lesser extent , will ensure that COPD patients are provided with reliable, efficient and effective management for all stages of their lives.

Conclusions

Base on the symptoms and complaints that the patient Mavis had displayed in this case study, and these include unexplained shortness of breath, being a smoker, exceeding the 40 years bottom line by fifteen years, having persistent cough, the red flag exclusion of the symptoms for pulmonary embolism, Tuberculosis, and pneumothorax,  she should be easily diagnosed as suffering from COPD, and be subjected to the spirometry test in an approved institution.

This would enable her to be provided with the managed care that is available across institutions that are working collaboratively to ensure the disease progression is severely inhibited.

 

REFERENCES

American Family Physicians (1998). Lymphadenopathy: Differential Diagnosis and Evaluation  AFP Vol. 58 Issue 6 pp.1313-1320

British Columbia Medical Association (2011). Chronic Obstructive Pulmonary Disease (COPD) Guidelines and Protocols Advisory Committee www.bcguidelines.ca/pdf/copd.pdf , 01/03/12

Ford, M. J., Ford, M., Hennessy, I., & Japp , A. (2005).  Introduction to Clinical Examination Churchill Livingstone, UK

Holistic Anatomy (2011). Symptomatic Treatment www.holisticanatomy.com/holisticanatomy_chapter21.pdf , 01/03/12

John, S. Pasche, N. Rothen, A. Charmoy, C. Delhumeau-Cartier, D. Genné (La Chaux-de-Fonds, Genève (2011) Tobacco staining on fingers: a simple tool to predict smoking-related disease? Allgemeine Innere Medizin Donnerstag, 12. Mai 2011, 12:15 – 14:15

Michigan Department of Community Health (2005). Asthma Prevalence, Severity, and Management for Michigan Adults Epidemiology Service Department www.mi.gov/documents/asthmaPrevSevMgmnt_127071_7.pdf , 01/03/12

Myers, K.A., & Farquhar, D. R., (2001). The rational clinical examination:  Does this patient have Clubbing?  JAMA (2001) 286: pp. 341–7

Murphy, L.R.,  (1996). Stress Management in work setting: A Critical Review of the Health Effects  AMJ Health Promotions 1996  Vol.11 pp.121-135

Roper, N., Logan, W.W. & Tierney, A.  (2000). The Roper-Logan-Tierney Model of Nursing- Based on Activities of Living Elsevier Health Services Oxford UK

Steen Land, K., Thun, M., Lally, C., & Heath, C., (1996). Environmental Tobacco Smoke and Coronary Heart Disease in the American Cancer Society CPS-II Cohort American Heart Association Inc. (1996). Vol. 94 pp. 622-628

Scott Richardson, W., Wilson, M., Lijmer J., Guyatt, G. & Cook, D. (2002). Differential Diagnosis American Medical Association

Respiratory Review Panel (2007). Respiratory Guidelines (Asthma  and COPD) for Family Practice 2nd edition  MUMS Guidelines Clearing House Toronto

Sparks Ralph, S., Taylor, C.M. (2007). Nursing Diagnosis Reference Manual 7th edition Wolters Kluwer/Lippincott Williams &Wilkins Health Philadelphia PA

Tseng, W.S., Streltzer, J.M., (2008). Cultural and Clinical Assessment Cultural Competence in Health Care  (2007) DOI 10.1007/978-0-387-7217_3 pp. 27-37

Turluin, B., (1994). Nervous Breakdown Substantiated : A study of the General Practitioners’ Diagnosis of Surmenage Zeist  The Netherlands Kereckebosch 19954

Wood, P.R., Smith, A.B., O’Donnell, L., Galbreath, A.D., Lara, M., Forkner, E., & Peters, J.I. (2007). Quantifying Asthma Symptoms in Adults : The Lara Asthma Symptoms Scale Journal of Allergy and Clinical Immunology(2007) Vol.120 Issue 6 pp.1368- 1372

World Heart Foundation (2011). Tobacco, Heart Disease and Stroke  Fact Sheet www.tscs.org/tobacco/factsheetHDstroke.pdf , 01/03/12

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