Patient Medical History Case Srudy

History and Physical Examination

The case study in question describes how a 35-years-old Mary, an engineer by profession is undergoing several symptoms after hiking and camping activities in the Appalachians. The given paper intends to evaluate the medical history of the patient, provide a suppositional nursing diagnosis, and develop a teaching and nursing care plan for the patient. It is relevant to relate the symptoms and signs of a disease as it helps in the treatment process and better recovery.

History

Mary says that she had been in her usual state of good health until recently when she presented her case to the medical practitioner that she had a rash on her face. The rash is across her face and the bridge of her nose, which became noticeable after spending a week hiking and camping in the Appalachians. Within the last one week, she has noticed that the lesions itch and are painful, especially when she goes outdoors. She is scared because she has never had such a rash in her life, and there appeared fatigue, fever, and weight loss. Within the last week, Mary enumerates that she has mouth soreness, an increase in muscle aches and pains, which are mostly felt in the wrist and hands respectively.

At the age of nine, she had a tonsillectomy for chronic strep throat infections, but since then, she has been healthy. Her family background shows that her father is healthy, and her mother has a history of rheumatoid arthritis. Thus, for a long time, Mary has been healthy, but it can be concluded that her health changed immediately after she had gone out for camping and hiking in the Appalachians. Moreover, she has confirmed that she does not feel any headache, sore throat, ear pain, chest pain, and issues associated with abdominal pain. She does not also feel any early morning joint stiffness and temperature intolerance, which shows that her present state can be treated. She does not smoke nor has she tried applying any medication. Hence, the treatment and diagnosis process will be easy for the practitioners.

Physical Examination:

Rashes on the face;

Weight loss;

Increased fatigue;

Mouth soreness;

Erythematous plaques scattered over the cheeks and the bridge of nose;

Sparing the nasolabial folds:

Normocephalic;

Atraumatic. Sclera white;

Conjunctivae clear.

BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min; temperature 100.3F.

Chronic Medical Illnesses: None specific except itching of lesions, which are painful;

Fever, increased muscle aches, and pain, especially in the wrist and hands.

Drug Use: None.

From the above symptoms, it is apparent that the disease needs to be treated with the best medication approach because of the possible results that it might lead to. Based on the fact that the patient in question has recently acquired the symptoms, it is appropriate to implement the necessary medication to ensure her quick recovery, which can only be attained by identifying the right steps that can be incorporated to counter the perceived disease (Gaberson et al., 2014). Following the contents of the physical examination is appropriate as it will help in the treatment of the disease affecting Mary. The symptoms named above were retrieved based on the historical background of Mary. Fundamentally, the symptoms mentioned above are, significant because they will guide the practitioner on the needed steps to treat the disease effectively.

The Presumptive Nursing Diagnosis

The presumptive nursing diagnosis for the disease in question is lupus based on some of the symptoms described by the 35-years-old Mary. The description coincides with those of lupus, hence, an indication that she might be suffering from the disease in question (Ackley & Ladwig, 2013). Lupus is an autoimmune disease whereby genes play a significant role in its development, but genes alone do not lead to the presence of lupus. The disease leads to skin inflammation and other joint parts of the body. Its effects or symptoms of the disease in question are chronic because they can last longer than six months, and at times, for several years (Collins, 2015). Thus, the relevant steps need to be put into consideration to counter the possible consequences that the disease might cause to the patient, i.e. Mary.

Teaching and Nursing Care Plan

Learning Results	Substance Delineate	Teaching and Nursing Strategies
Illustrate the normal healing for lupus; Describe symptoms and signs that are brought about by lupus; Identify the tools that need to be utilized to ensure that the symptoms of the disease are fully treated; Demonstrate how to apply medication on the rashes; Come up with the right steps in case the situation becomes complicated; Identify the time, date, and location needed to follow-up on how the treatment process is going on.	Normal lupus healing process; Signs and symptoms of lupus are rashes on the face, weight loss, and increased fatigue, mouth soreness, itching of lesions, which are painful, fever, increased muscle aches and pain in joints. The tools that will need to be used to treat lupus: Medication Surgery Symptom tracker Therapy treatment Enumerate on how lupus can be treated to evade possible damages to the patient by ensuring that the treatment is initiated effectively and professionally. The tools that can be accessed for the purpose of inquiry issues are health clinic and utilization of the emergency department. Clarify with the patient on matters associated with the treatment approaches in terms of place and period set aside via the prescription.	The use of audiovisuals will be appropriate for normal lupus healing process, as it will ascertain the patient that the process is being implemented in the right way. Talking about the policies or methods that can be initiated for the disease, i.e. lupus. The use of the audiovisual tool to show the infected areas will help the treatment process to be effective. Students or nurses will be offered handouts with descriptions of the signs and symptoms of lupus to inform them about the condition, its symptoms and treatment methods. The tools required for the treatment of lupus will be illustrated to help in the provision of better medication incorporation. Show how the process of treating lupus can be undertaken, to convince the patient that the process is safe and appropriate. Also, handouts illustrating methods of treating the disease will be offered. Talk about the available tools and offer handouts meant to help in how they can be utilized to counter the disease.

Conclusion

The paper enumerates that one can know the type of a disease he or she is suffering from based on the symptoms and signs exhibited. It is, therefore, appropriate to counter check with such signs and symptoms to counter the further damages that can be evaded. It is noted that Mary, an engineer and at the age of 35 years, has acquired a disease that needs urgent treatment to reduce or evade possible damages that the body can withstand. From her symptoms, i.e. fever, loss of weight, soar mouth, rashes on her face, and nose and lesions itching with pain indicate lupus as the primary disease. Thus, drafting of a teaching and nursing care plan is significant because it will help to ensure that the right form of medication and treatment is put into consideration. Fundamentally, the probable outcome of knowing the symptoms, signs, and treatment procedure is the presence of better medical application, in terms of recovery.

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