Older Issues on Health, Assessment Example

The Case Scenario:  Ms. Brown is a 62 year old woman who has presented at my primary care practice complaining of an uncomfortable rash to her back for two days.

Four Differential Diagnoses:  i)  An allergic reaction to a medication  ii)  An anxiety reaction  iii) An allergic reaction to a shirt washed with a particular detergent or metal such as in jewellery  iv) Heat Rash.

History of Present Illness:  Questions I would ask in order to arrive at a diagnosis:

What, if any, prescribed medications are you taking?  For how long have you been taking them?

Are you taking any over-the-counter medications and/or health supplements?

Although the patient’s vital signs fall within the acceptable range for her age, they bear watching, especially the systolic blood pressure, which can be affected by anxiety.  With this in mind, I ask the patient if she knows what her last vitals results were. I ask her if anything has changed in her life recently (example:  a new job, a move); and if so, how this affected her.  I also ask if anything is bothering her and whether she feels stressed and/or anxious.

With respect to a possible reaction caused by wearing something that was washed by a different detergent. I ask the lady whether she has changed her brand of detergent lately; and find that she has—to a bargain brand that results in her sneezing nearly every time she uses it.  To top it up, I notice that she is wearing a metal chain, which was a recent gift to her.  It is a hot day, but the patient is bundled up tightly.  I ask her if she feels warm to which she replies in the affirmative, saying it is so especially outside and particularly when she walks quickly.  This fits with what is written on “Mama’s Health.”This could also result in a somewhat high systolic BP.  However, at the end of my exam, my diagnosis is “Back rash due to anxiety.”

References

Mama’s Health (2000 – 2012).  Retrieved on October 06, 2012, from http://www.mama’shealth.com/skin/brash.asp