Taking a Physical Examination SNAPPS History Case Study

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Running Head: HISTORY TAKING AND PHYSICAL EXAMINATION HISTORY TAKING AND PHYSICAL EXAMINATION 5SNAPPS History Taking and Physical ExaminationCCThis patient is a 61-year-old male who presents to the clinic with a chief complaint of uncontrolled blood pressure for a follow-up visit.HPI statement using OLDCARTS dataThe onset of symptoms was 1 year ago and is now progressively increasing.Lightheadedness and muscle weakness are constant. He experiences a sharp headache in the left temporal region. He reports that the headache is of a throbbing type and rates it at 7/10 using the NPRS. The headache is progressive, accompanied by light sensitivity, nausea, and vomiting. Loss of consciousness associated with the headache is negative. He reports no convulsion but positive for visual changes; further, other special senses are okay except a burning sensation experienced in his eyes. He experiences spasmodic pain and is unable to eat during the headache episodes.He reports experiencing dry mouth, making it difficult to feed properly due to the pain while swallowing.The patient experiences joints pains both in the lower and the upper limbs, which he graded 9/10 based on the severity.The administration of antipyretics and analgesics alleviates the headache. Joint pains were also alleviated by NSAIDS given to him.The joint pain was aggravated by walking or lifting heavy objects, while the headache was aggravated by upward posture.Associated symptoms were chills, general body weakness, malaise, night sweats, fever, and insomnia due to his pain.His past medical history revealed that about a year ago, he was diagnosed with Rheumatoid arthritis; he reports being put on corticosteroid therapy which markedly alleviated the symptoms. This was followed with methotrexate administration which proved ineffective up to the time of visit.The patient reported having had a hip replacement surgery about 5 years ago.He reports having completed the vaccination when he was young, including the influenza virus vaccine.He takes Bystolic 40mg daily, hydralazine 25mg twice daily, and losartan daily due to hypertension. Other medications taken include omeprazole 20mg daily, sildenafil 100mg, and atorvastatin calcium 20mg.The patient does not have an allergy history.On his social history, the patient is a graduate of Michigan state university, having attained a degree in Ecology and environment.He reports sharing a bottle of wine with his wife during daily evening dinner, does exercise regularly, and has not regulated fat and salt consumption.His family history reveals that his father succumbed to diabetes and hypertension. His mother lives with osteoporosis and hypothyroidism. He has three brothers and one sister with no known chronic illnesses.Pertinent ROSGeneral-looked febrile and tiredHead and face-no pain, loss of sensation, traumatic injuries.Eyes -reports episodes of burning sensation, negative for inflammation, Infections, positive for visual changes.Neck-no masses, positive for enlarged pre-auricular lymph nodes.Ears -negative for infections, inflammation, or changes in hearing.Nose and sinus-No pain, obstruction, or possible discharges, positive for epistaxis.Mouth and throat -No dental problems, positive for dysphagia, odynophagia, and dry mouth.Skin -negative for easy bruising, discoloration, hair loss, dry skin, and positive signs in the pre-auricular region.CNS-positive for lightheadedness, headaches, faints, dizziness, gait disturbances, and slight confusion.

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Respiratory system -lung sounds clear, no coughs, shortness of breath, wheezing sound, dyspnea, tachypnea, nasal congestion, and any other respiratory distress.Cardiovascular system- Negative for chest pains, dyspnea, palpitations, oedema of the lower extremities, tachycardia, increased heart rate, tachypnea, shortness of breath with overall normal breathing patterns.Gastrointestinal system-negative for abdominal distention, hemoptysis, abdominal pain, vomiting, dyspepsia, and dysphagia…

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…patient and getting to the management of the condition has been very educative and important in my career; this has not only made me realize my dream of becoming a wonderful nurse but also boost my confidence and my relationship with people in difficulties through the change of empathetic personality and feeling the sense of sympathy to the patients.The patient I chose for the SNAPP assignment was a 61-year-old male who presented with symptoms of cardiovascular and respiratory complications, e.g., dyspnea, chest pain, exercise intolerance, pain in the joints, profound headache, palpitations, GIT symptoms, and many more (Beneto et al., 2019).These unique symptoms triggered my thinking into arriving at the correct diagnosis because this patient was old and took alcoholic drinks almost every day. My point of interest was to find out the disease of old age, which includes hypertension, osteoporosis, benign prostate hyperplasia, and diabetes ketoacidosis, to the moderately to chronic drinkers like the patient I chose. This exposure further led me to learn a few symptoms that are quite often omitted but are a leading route to making these diagnoses.Recent studies in the health care sector have shown some medical conditions that affect patients with advanced age due to immunosuppression that comes with old age. However, much of these conditions are attributed to affluent lifestyles and the inability to subject the body to sufficient and regular exercise (Sarkar et al., 2019). Antibiotic sensitivity testing has helped make treatment plans for aged patients. Much care has been taken to boost their immune system, especially with the emergence of the bothersome COVID-19 pandemic. Designing the gold standard of treatment for these patients requires proper history taking and physical….....

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