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Medical Case Study

Free Case Study Analysis Example

The case study involves a 35 years old lady who is an engineer by profession. Recently, the woman had completed her master’s degree in the same field and for five years she has been cohabiting with her boyfriend. According to the woman, she leads a healthy lifestyle as she denies any past usage of illicit drugs or smoking. However, the lady agrees that she takes a glass of wine almost every night after dinner. Her family’s medical history is relatively stable as the father is healthy, while the mother has been diagnosed with rheumatoid arthritis. At age nine, the patient had a tonsillectomy as a result of a throat infection. However, the woman has been healthy throughout her adulthood as she has never been hospitalized in the past. The given paper revolves around a case study of a middle-aged woman who went to the medical examination room citing a rash on her face.

Historically, the woman has never been diagnosed with such rush before. The condition has persisted for a week now where it has continued to spread over her face. However, she claims that the disease has not spread to other parts of the body. The woman also claims that lashes are painful and itchy. Before noticing the new development on her face, she had spent about a week in adventure, where she had participated in camping and hiking in the Appalachians. The patient is also of the opinion that the condition is not a result of environmental factors, but agrees that it accelerates whenever she exposes her face to the environment. For the past one week, the woman has not tried either herbal or clinical medication to calm the condition (Rollnick, 2014).

After further interrogations, the patient denies any usage of new detergents, lotions, soaps, or exposure to new environmental factors. Such conditions can be responsible for facial rashes as a result of body’s reaction to foreign cosmetics. The patient has not also been exposed to new types of foods or medications. Lack of historical diagnosis with such a rash is a clear indication that it is a sign of a new infection in the patient’s body. Lack of exposure to conditions that might ignite or accelerate such condition only strengthens the assumption of a new infection.

It is also determined that the facial rash is accompanied by other conditions such as body fatigue, massive weight loss, and fever. The three states have developed within one week period that she had started noticing rashes on her face. After further interrogations, the patient denies experiencing other health conditions that regularly accompany the three in case of a serious health problem. These conditions include severe headache, ear pain, sore throat, sinus or nasal congestion, cough, regular shortness of breath, constipation, frequent abdominal pain, diarrhea, or pain while passing out urine. Lack of these body symptoms does not necessarily rule out the existence of a severe health condition, but might indicate a development of an illness that has not developed completely. The condition can also indicate a common rash that might be a result of various allergies.

The patient also confessed that she had mouth soreness, a condition that may cause bad breath and difficulties in eating, and both muscle and joint pain. The muscle aches and pains were severe in the wrist and hand. Such a condition can disable a patient from carrying out hard activities that require more energy than others. The condition can also accelerate severe fatigue after undertaking a simple task. The patient feels weak and is regularly compelled by the situation to stay indoors and avoid hard labor. She further denied morning joints stiffness, a condition that disables a patient from engaging in any mobility activity as joints stiffen especially in the morning. She also denied polyphagia and polyuria. In most cases, these conditions accompany joints and muscle pains that discourage movement or carrying out of challenging activities. Lack of the two primary symptoms affecting the joints may also signify the existence of a chronic disease that has not developed to maturity, yet it is in the patient’s body. It might also be a sign that the individual is normal and free from any life-threatening illness. Thus, there is the need to carry out thorough tests on the patient’s body to determine the cause of the symptoms in question (Swearingen, 2013).

Indication by the patient that she does not smoke nor engage in narcotic drugs proves that the health conditions experienced by the patient are not a result of drug abuse. Technically, this is because drugs, especially smoking, promote negative health conditions such as chest pain, cough, muscle and joint pain, and headache. Such symptoms are observed especially when the behavior has persisted for an extended period hence weakening the body of the patient. Lack of hereditary medical conditions in the history of her family rules out the existence of an inheritable health condition, since the rheumatoid arthritis, a medical condition suffered by the patient’s mother, has not been medically proven to be hereditary in nature. However, this increases the chances of the existence of a lifestyle disease that might be a result of engagement in various uncontrolled behaviors.

After conducting several basic medical examinations, it was determined that the patient was healthy. For instance, the blood pressure test resulted in BP 112/66 mm Hg, an indication that the patient’s blood was not under pressure. Medically, it has been scientifically proven that an ordinary healthy person should have a blood pressure of BP 120/80 mm Hg and below after testing. The test also revealed that the patient is out of danger of acquiring hypertension, a fatal illness especially if it is not detected and controlled on time. The patient’s heart rate of 62 BPM indicated that she was free from any cardiac disease. Technically, this is because a healthy person free from any influences of physiological factors such as body exercises and swimming should have a heart rate of 70BPM and below.

Another medical test carried on the patient was the patient’s respiratory rate, which resulted negative. For instance, it was determined that the patient had a respiratory rate of 12 breaths per minute. A healthy person should have a respiratory rate of between 12-20 breaths per minute. The result indicated that the patient is free from any respiratory infections, which in extreme cases can cause the symptoms that the patient had exhibited. The result also shows that the patient had no difficulties breathing, a condition that acts as an indication of the existence of a chronic ailment. On the other hand, the patient had normal body temperatures after a temperature test was taken on her. The test indicated that she had a body temperature of 100.3°F, which is fine since a normal human being, should have a body temperature of about 97.5°F, which translates to 36.4C. According to the test, the patient’s body temperature was within a healthy range. Further necessary tests also indicated that the patient had various erythematous plaques spreading on the bridge of the nose and all over the cheeks. There were also numerous shallow ulcers scattered on the walls of the buccal mucosa. There were no signs of thyromegaly or lymphadenopathy on the neck.

Based on the given information, my presumptive nursing diagnosis is HIV/AIDs. Based on the insightful medical knowledge, most of the symptoms exhibited by the patient are widely associated with HIV/AIDs. For instance, the existence of a painful and itchy body rash especially on the torso and the upper part of the patient’s body is ranked among the primary symptoms. In most cases, the sign appears after a period of about one week after an exposure to the virus. Severe muscle and joint pain are also major symptoms associated with the virus in its early stages. The symptom is a result of the body’s defense system (red blood cells) exhausting the body by trying to eliminate the virus. Lack of other significant symptoms in the patient’s body at this stage cannot entirely dismiss the probability of the HIV in the patient. For instance, no sore throat may be a result of tonsillectomy procedure carried out on the patient while young.

For the teaching and care plan in the case, the nurse student should strictly follow the following seven steps to ensure that the patient learns and achieves after the lesson.

  1. Specify the content that must be included. For example, teaching methods, learning objectives, the expected time frame, and the evaluation.
  2. Tailor the plan to given conditions. For instance, the patient should participate in a group for at least seven day a week discussing various ways of healthy living.
  3. Begin with the most anticipated learning outcomes that indicate the length of time and content.
  4. Anticipate the various questions that a patient is likely to ask and provide answers.
  5. Specify the suitable teaching method.
  6. Make the decision on benchmarks for the expected learning outcomes.
  7. Include the medication lessons on the outlined patient’s plan.

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