Medical Assessment Initial Patient Analysis Chief Complaint Essay

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Medical Assessment

Initial Patient Analysis

Chief Complaint

Discomfort in lower back.

HPI

Patient is a 78-year-old woman presented as disheveled, with bug bites throughout her body, and exuding a foul odor. Cognitively, she orients only to her name with a BMI of 30 and a minimal understanding of the English language. She is able to nod "yes" or "no" to questions, but calls the nurse "Mother." She is unsteady on her feet, and has a fine "pill-rolling "tremor in her left hand. He legs are quite cool to the touch, hairless, and toe capillary refill is greater than 2 seconds.

Past Medical History

Unknown, but patient appears to be in distress both physically and psychologically.

OBJECTIVE

General App.

Poor, disheveled, may not be receiving adequate care or living in an environment with enough food or warmth. BMI of 30 is technically obese, which also may indicate the patient is not receiving adequate hygiene.

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Bug Bites

Patient may be suffering from a toxic reaction to bug bites, or may be homeless, living outside and being bit, or sleeping in unhygienic areas (bed bugs, etc.)

Foul Odor

Foul odor may be from lack of hygienic living conditions.

Unsteady on Feet

Confusion and potential for malnutrition, diabetic attack, or stroke.

Pill Rolling Tremor

Suggestive of Stroke, Parkinson's, Hyperthyroidism, or certain drugs.

Legs Cool to Touch

Suggesting some sort of arterial disease or diabetes

Low Capillary Refill

Suggests lack of circulation, arterial issue or some sort of blockage

Areas for Focused Assessment- The combination of syncope, vertigo, vision, and memory issues combined with the patient's appearance, odor, and BMI suggest a potential cerebral or arterial issue and inability to receive proper care. This is based on:

1. Unsteadiness on feet, dizziness, and vertigo -- may be medication, lack of medication, malnutrition, arterial or cerebral issue. Neck and.....

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"Medical Assessment Initial Patient Analysis Chief Complaint" 07 November 2013. Web.5 June. 2026. <
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"Medical Assessment Initial Patient Analysis Chief Complaint", 07 November 2013, Accessed.5 June. 2026,
https://www.aceyourpaper.com/essays/medical-assessment-initial-patient-analysis-126559
   

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