Comprehensive Patient Assessment: Case Study Report

Instructions

Identifying data

Name: Julie Thomas

Date of Birth: 20^th January 1972

Julie Thomas is stated as a middle-aged lady (48 years old) living in the suburban parts of Sydney.

1. b) The patient’s presenting problem

In this case, the nurse started with a thorough and complete and comprehensive biopsychosocial assessment of the patient whose name is Julie Thomas. In the interviewing process, the assessment began with history taking where it was revealed that the patient had an appendectomy about thirteen years back and that her present problem of shortness of breath as well heart palpitations started recently about 6 months back which was an important finding. She was trying to cope positively and want to improve herself. As her the other findings, she was not in substance abuse and alcohol abuse.

1. c) Initial observations

• The thorough physical examination, it was revealed that the patient was obese, her body mass index was 31 and had symptoms of mild hypertension.
• Her blood pressure was found to be 140/85. The findings were documented in a clear and professional language, according to the evidence-based protocols of practice.

Preliminary Investigations

• The blood reported suggested that the cholesterol was within the normal limits as well.
• Only in the second visit to the general practitioner, when the Electrocardiogram was taken and the sinus rhythm was in the normal range and there was no ischemic change that was seen.

General appearance and behaviour

• Throughout the interview, the nurse maintained eye contact with the patient, listened actively and demonstrated effective communication skills that helped the biopsychosocial assessment process to run on a streamlined basis (Santos et al., 2018).
• Julie was cooperative in nature while undergoing the interview process and was well groomed too.

Speech

• Julie was soft-spoken and her heartbeat was normal while speaking during the interview process.

Affect and mood

• Julie had a normal affect range.
• The mood also had congruency with content.
• Julie was also anxious many times.

Thought content

• She is afraid because she was suffering from a heart attack and the chest pain was making her breathe with difficulties.
• She responded to instructions and questions appropriately.

Cognition

• Julie was alert.
• She was also able to answer all the questions and recall her full history without many difficulties.

Insight and Judgment

• July accepted the fact she has been suffering from a severe anxiety disorder which required urgent treatment.
• She also showed judgments along with insights regarding treatment for her illness.

1. d) History

Medical history

• Appendectomy at the age of 13 years.
• Mild hypertension with 140/85 blood pressure without any diabetes history.

Psychiatric history

• Anxiety takes over her sometimes, but she has not sought any treatment for that.

Drug and Alcohol History

• Does not smoke.

Current social supports

• Cannot drive.
• Married woman and lives with her husband and son, who lives in Melbourne.

Social circumstances

• She works as a bank clerk and has been off from that for one week.

1. e) Other considerations

• Julie has been avoiding exercise and having sex which she thinks might stress her heart.
• Julie also has social isolation and fails to visit a pub.
• Her husband is also fed up with her condition.
• She thinks that working can trigger her heart symptoms.
• She cannot go out alone due to the fear of a heart attack.

1. f) Investigations

• ECG or electrocardiogram
• Urinalysis
• Urine drug screen
• TFT or the Thyroid function test
• FBC or UEC (Full Blood Count or Urea and Electrolytes test respectively).

1a – What is going on here?

It is crucial to be understood that the various aspects of the biopsychosocial signs and symptoms of health are interrelated with each other and the history of the patient along with the present situation of the patient is also very critically connected, which is to be analyzed crucially by the nurse, attending the patient. As per the body mass index of the patient, the patient is obese. The blood pressure of the patient was found to be borderline high that is 145/85. The patient did not have any cholesterol problem such as dyslipidemia and hyperlipidemia or hypercholesterolemia. As per the history of the patient, the patient had a surgery that is appendectomy about 13 years before and the history of present illness began only 6 months ago when the patient presented with the signs and symptoms of shortness of breath and heart palpitation along with chest pain in the retrosternal chest pain. She visited her general practitioner three times and in the second time, he had an electrocardiogram that showed no abnormalities. The heart rate in the present assessment was found to be 92 beats per minute which are normal and it is important to be noted that in the biopsychosocial assessment, it was also found that the patient has stress, anxiety, worried that is affecting her behaviour and functional independence slightly. The blood pressure of the subject was found to be borderline high with the rate of 145/85 mmHg. It is important to be noted that although the patient did not have shortness of breath during the assessment there were certain changes in the rhythm of breathing of the patient was assessed that increased the heart rate, for short intervals of time. The airflow to both the lungs of the patient was normal and the respiratory examination which was undertaken thoroughly did not reveal any abnormalities and the patient also did not have any chest fillings. Performing the observation and physical assessment, it was found that the patient did not have any edema or fluid accumulation in the limbs that would have been significant for the congestive heart failure. There were no signs of cyanosis either but as the patient was undergoing palpitation at times, it was important to note the changing respiratory rate of the patient. The capillary refill time was normal. On the neurological examination that was started with the observation, it was revealed the subject was nervous and shaky and agitated. The sensorimotor functioning of the patient was normal and in the mental health examination, it was found that the person is oriented to place, person and time, has normal memory and recall, thinking, learning, language and intact. The cognitive functioning was normal, although the responses that were received by the patient to each question as a response to the instruction being given to the patient – was delayed. The psychological examination was performed was MSE that is known as the mental status examination. In the parameters of the ‘thought process’, it was identified that at times had a flight of ideas and tangential in the thought processes. In most parts of the assessment though, the conversation was linear and logical. In the ‘thought content’, the patient had all the patterns of thinking normal but the phobias were present. She also had some elements of paranoia, characterized by things she could not explain. She was afraid of deteriorating her health further and she was panicking in these moments while talking about the same, it resulted or rather attributed to the heart palpitations and changing in the breathing rhythms and rates of the patient. In the last parameter, the patient did not show or present any symptoms of the perceptual disturbances. Using the HONOS scale, it was found that the patient has increased episodes of insomnia, anhedonia, lack of interest in the social activities that were previously enjoyed. She had increased feelings of low self-esteem, social withdrawal as well as mild issues with the behaviour and functioning about activities of daily life. The most important finding is that the person has ‘generalized anxiety’.  

Assessment Tools

Mental Status Examination of MSE

General appearance and behaviour

• Throughout the interview, the nurse maintained eye contact with the patient, listened actively and demonstrated effective communication skills that helped the biopsychosocial assessment process to run on a streamlined basis (Santos et al., 2018).
• Julie was cooperative in nature while undergoing the interview process and was well groomed too.

Speech

• Julie was soft-spoken and her heartbeat was normal while speaking during the interview process.

Affect and mood

• Julie had a normal affect range.
• The mood also had congruency with content.
• Julie was also anxious many times.

Thought content

• She is afraid because she was suffering from a heart attack and the chest pain was making her breathe with difficulties.
• She responded to instructions and questions appropriately.

Cognition

• Julie was alert.
• She was also able to answer all the questions and recall her full history without many difficulties.

Insight and Judgment

• July accepted the fact that she has been suffering from a severe anxiety disorder which required urgent treatment.
• She also showed judgments along with insights regarding treatment for her illness.

The patient has obesity and in a pathophysiological correlation, the hypertension of the patient which is although borderline high b u t has developed due to the underpinnings of obesity in the patient. It is critical to understand that although the patient does not have a history of diabetes mellitus or hyperlipidemia or any other cholesterol-related issues that have contributed to the complexity in hypertension – but the symptoms are greatly related to obesity. The patient has a work-life as a clerk in the bank and as the nature of the job is both straining and sedentary, the socio-demographic factors here has greatly contributed to the increased blood pressure and obesity in the patient. Sedentary lifestyle without the proper time to eat, rest and exercise hampers the quality life of the patient as well as leads to the development of pathophysiological processes that causes the lifestyle diseases like stress, hypertension and obesity (Vance et al., 2019). The patient has a family and due to lack of work-life balance, the stress and the anxiety levels have increased in the patient leading to the psychogenic rise of blood pressure in the patient. It is to be noted, that the age of the patient is 48 years which signifies the fact that she is a menopausal phase that has again contributed to the cause of essential hypertension, which is due to the hormonal changes in the post-menopausal phase. The patient is not taking any medications for high pressure which is another critical reason that the blood pressure of the patient has become high, even it is borderline hypertension. The underpinning of obesity is directly associated with myocardial functioning and atherosclerotic consequences that can then affect the cardiovascular functioning, leading to palpitations and angina. It is important to be noted that in the history of present illness, the patient has presented with angina which implicates the palpitation and shortness of breath, to be a myocardial issue. All the problems have significantly contributed to the symptom of ‘generalized anxiety’ in the patient that will be discussed further.

As the investigation did not show any abnormalities, the symptoms can chiefly be attributed by metabolic reasons of being obese and that of the anxiety-related panicking that has actually caused the palpitation in the patient (Finnegan et al., 2018). Lack of physical fitness, lack of physical activity, lack of proper healthy nutrition and age are the factors that have led to the development of hypertension, palpitation and shortness of breath and resulted in anxiety. Irregular breathing pattern can cause irregular heart rate, due to sinus arrhythmia and this contributes to anxiety. The patient has symptoms of stress and anxiety throughout the assessment procedure and as the patient suffered from panic, worriment and pessimism; it had a significant effect on her health. As she is worried about returning to work and about her family plus her own physical health, it has affected her mental and social functioning to a great extent as well. Cardiovascular and respiratory issues in addition to hypertension and obesity have contributed to stress, social isolation and detachment, low self-esteem that has in turn added to the anxiety. The neurophysiological cause of low mood, anxiety and low esteem can be due to the reduced adrenaline level in the body that causes lethargy and emotional issues. It is to be noted that the changes in the neurochemical transmission of the person, has also played a huge role in the development of stress, anxiety as well as withdrawal, low mood and anxiety in the person. The levels of glutamate, Cholecystokinin, gamma-aminobutyric acid, serotonin are modulated with the emotions and the down-regulation of the neurohormones lead to the development of the depression and anxiety in the person (Nightingale et al.,  2017).  The deficiency of the neurohormones such as that of melatonin and serotonin results in the development of insomnia that causes fatigue and depression in the mood along with increased sleepiness in the morning that affects the daytime functioning of the patient and affects the functional independence. The limbic system is centre for emotional control and in the cases of the sleep deprivation, the disturbances in the neurotransmitter levels affect the limbic system, greatly, giving rise to the adverse human behaviour such as anxiety. Fear and anxiety are closely associated with emotion and behaviour that has the common underpinnings of the pathophysiological mechanisms or rather the above mentioned neuropsychological mechanisms (Moore, 2019). The connection between the hypothalamus and the limbic system is highly involved in the development of anxiety, due to central obesity and also insomnia.

Preliminary Investigations

 There are further assessments that are required to undertake in order to understand the actual etiology and to reach the nursing diagnosis about the actual problem that the patient is suffering from. It is important to be noted that the patient, as mentioned above have a range of clinical signs and symptoms which is due to the multiple problems, characterized by lifestyle diseases. As the patient is a not taking the medications for hypertension which is a chief issue in the patient, the further tests to understand the exact reasons of non- adherence has to be undertaken in order to understand the mood, behaviour and effect of the subject (Lall & Restrepo, 2017). As the patient has borderline hypertension and this high blood pressure is associated with heart palpitation and shortness of breath along with angina, the latter has presented when the patient visited the general practitioner for the second time – hence it is highly important that the further examinations are undertaken in collaboration with a doctor that is the general practitioners. A thorough cardiovascular examination followed by investigations such as electrocardiogram, Doppler test and checking for the vascular insufficiency is the other areas that are very important to be further assessed in the patient, to reach a comprehensive diagnosis (Monterroso, Sá & Joaquim, 2017). Information about the blood gas analysis is also very important as the patient had complained about shortness of breath that was in the initially presented in the history of present illness, about six months back and that is why, to check off any blood gas complication and ventilation-perfusion complications that is insidious in onset and progression – is important. The blood gas analysis is another very important and rather very critical investigation that should b requested by the nurse to check for any cardiorespiratory discrepancies. It is also important to understand the nature of angina, whether it is stable, unstable or of the prinzmetal type has to understood and assessed as well and that is why clinical monitoring of the patient is highly important. It is also very important that a clinical psychologist is collaborated with performing the specialized cognitive, depression and psychosocial dependency on alcohol and other drugs in order to understand any underlying factor of the anxiety, anhedonia, stress, mood and esteem issues and disruption of social and self-identity – that are symptoms present in the patient (Williams et al.,  2019). Obesity is greatly implicated with negative body image issues and emotional, behavioural derangements and that is why a behavioural psychologist can be and should be collaborated with reach further findings. The history of present illness mentioned angina in the retrosternal position and that is why, it is highly important that the cardiologist should have collaborated with the nurse to check the exact position of the patient, when the patient feels the signs of angina and this will be a very important finding, to inform the diagnosis and care of the patient in the future. Other than these, the reason for social isolation and low esteem has to be investigated further to check for correlation with obesity and other symptoms of the patient.   

General Appearance and Behaviour

1d- What does this all mean?

 According to the above-mentioned signs and symptoms of the patient, the biopsychosocial needs of the patient are many and multifaceted. It is important to be noted the weight loss program is the primary health care intervention that should be started as the immediate intervention to address the biological needs of the patient that is obesity.  The nurse should collaborate with the nutritionist or a dietician in order to develop a diet chart and the nutritional plan for the patient (Maxwel et al.,  2018). The nutritional as well the all the lifestyle change needs of the subject is very pronounced and it is highly important that the loss of weight along with a healthy lifestyle will solve most of the patient problems. The physical fitness needs and the physical activity needs are very important to be noted in this case study and that is why it is important that the patient is administered and taught the physical exercises by the nurse in collaboration will the physiotherapist. Next, for the cardiovascular and respiratory issue caused functional disturbances, the functional needs in the person are a huge problem and it is important and also very crucial that the functional needs of the person are taken care of with accurate interventions. The physical exercises such as cardio exercises, breathing exercises can not only improve the physical health and functioning of the patient but the mental functioning as well (Wade & Halligan, 2017). Physical exercise has been reported to improve the levels of the cognitive functioning and improve attention as well that then improves the irradiation process in the neuromuscular system, thus improving physical activity and conditioning to different levels of activities. As for the deficits in the functioning, the patient has activities of daily life needs as well. The activities of daily life training should be started by the nurse, in collaboration with a physical therapist and occupational therapist, so that her biopsychosocial needs are addressed from all the perspectives and provide her with the required improvements at the functional level so that she can return to work as well. The level of stress and anxiety in the patient is critical and the patient has mental health along with sleep and social needs and the psychosocial needs (Weldam, Lammers n& Schuurmans, 2016). The anxiety, anhedonia, stress, mood and esteem issues and disruption of social and self-identity are the major issues and that is why the nurse in collaboration with the clinical psychologist or psychotherapist should administer cognitive behavioural therapy to the patient in order to import the distorted cognitive patterns (Kim et al., 2016).  The various factors such as obesity and hypertension have a negative effect on the body image and emotions of the patient leading to social isolation and that is why, the psychosocial interventions are such as interpersonal therapy, problem therapy is very critical. She is currently not on medications such as antihypertensives and that is why obesity along with angina, shortness of breath as well as heart palpitations needs medical attention with medications and these are the important aspects of the physical needs. The family counselling, talk therapy along with the promotion of sleep and relaxation are critical to the sleep needs and the psychosocial needs of the patient.

Speech

References

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