History & Physical, Case Study Example

Subjective data

Subjective data when retrieved during a physical examination procedure pertains towards expressions of the patient or if he/she is a minor the accompanying adult who has sound knowledge of the patient’s condition. In the case study offered for critique while the patient is a minor at age 14 there must be some confirmation of symptoms he could have expressed. As such, this data begins by identifying the patient/client as 14 y/o African American male. Source and Reliability: patient’s mother and the data continue identifying the mother who is not he patient and this information certainly is unnecessary and should be revised (Case study tendered, 2013).

Secondly, the chief complaint has been recorded to be excruciating pain, which was not reported by the patient/client neither mother. Thirdly, the onset, and history come after the chief complaint, which should have preceded it in a scientific physical examination (Seidel et.al, 2010). The examiner ought to have taken a history inclusive of the onset before jumping to the chief complaint (Case study tendered, 2013).

Objective data

Objective data is derived when the doctor or physical examiner conducts a series of tests to rule out some of the subjective data that was retrieved. Essentially, first the examiner makes a declaration of ‘Eyes: Good vision, does not wear contacts or lenses, no redness, drainage, itching or excessive blinking observed. No visual field abnormalities, no deviation of the eyes, positive pupil light reflex’ (Case study tendered, 2013).

Vision good had to be supported by an eye examination, which was not mentioned. Secondly does not wear contacts appears to be subjective data since the client/patient has to say this to the examiner. Thirdly, with a chief complain of excruciating pain examination of the patient’s eyes for contacts seems irrelevant (Swartz, 2010).

References

Case Study (2013). History and Physical. Tendered.

Seidel, H. Ball., & Dains, J. (2010). Mosby’s Guide To Physical Examination. New York Saunders

Swartz, M. (2010) Physical Diagnosis. History and examination. New York Saunders