The patient is a 32 years old married African American with three kids. The reason for care is because the patient is feeling pain on her right leg slightly above the knee. PQRST was used to assess the present illness in this scenario. When it comes to the provocation, the patient was playing softball with her friends two days before encountering this feeling. The pain is aggravated when she is active doing home chores or walking around. The quality/quantity of the pain is dull and intermittent. The pain radiates just above the knee, and it does not move or travel around. The patient rates the severity of the pain on a scale of 0 to 10 as a 3. The patient perceives herself as being healthy despite the pain she is currently experiencing. She does not smoke, and neither has she ever done it in the past.

On past medical history, the patient does not have any known drug, environmental, seasonal, or food allergies. Currently, she is not on any medication. She only takes vitamins as it is required. The patient was brought up by both her father and mother. She also has a sister and a brother. None of the family members has any known chronic health issues. Her three children are also healthy. When it comes to the review of system, her energy level is generally good; height is 5’5, weight 148lbs and a BMI of 25. The patient does not have a headache, has never had a seizure, no balance problem, no numbness, no stroke history, all senses seem to work well, and her work does not expose her to any occupational hazards.

For the physical exam, the focus was on the assessment of the integumentary system. When it comes to the vital signs, the temperature was 96.8, pulse 72, respiration 16, and blood pressure 112/64. The patient has an audible and regular speech, and both long-term and short-term memory are intact. It is also apparent that the patient is alert, and has favorable insight and judgment. The patient had the ability to smell and recognize coffee with her eyes closed through one nostril occlude. This ability to smell signifies cranial nerve 1 olfactory nerve test is negative. The patient’s ability to read was also positive hence making the cranial nerve II Optic nerve test negative. This was ascertained by the fact that the patient can read a sentence from the newspaper. The patient’s pupil is evenly dilated too. She can also follow finger direction, and the pupils can react to light, has the ability to abduct the eye and move her eyes too. As a result, Cranial nerve III oculomotor, IV trochlear and VI Abducens nerve test is negative.

Cranial nerve V, trigeminal test is negative too since the patient has the ability to have full facial sensation and motor function on both sides, and there is no signs of drooping face on side.  She also has the ability to frown, smile, and close eyes tightly. She was able to express when she tasted something bitter using her facial expression. As a result, Cranial nerve VII, facial test negative. The patient can also hear normal conversation and has no problem with balancing and also has the ability to gag, swallow and taste. This makes the ranial nerve IX glossopharyneal and X vagus nerve test negative.The patient has the ability to rotate the head forcibly against resistance, and no weakness was observed on both sides. There was the ability to move the tongue around evenly and when she was asked to pronounce some words that were provided, her speech was distinct and clear. This was an indication of the Cranial nerve XII hypoglossal test being negative.  The patient’s neck has normal muscle size limits for age and symmetric bilaterally. She was able to move her extremities through a passive range of motion with a mild even resistance to movement. This was through Checking the patient’s upper and lower extremities strength and tone by supporting the upper and lower extremity. There was no involuntary movement that was observed.

She was able to do the rapid alternating movement at the same time on both fingers turning equally, at a rhythmic pace. She was able to move her index finger to touch my finger and then move it back to touch her own nose. Patient’s movement was accurate and smooth. The patient was able to place her heel to the opposite knee and run it down the shin from the knee to the ankle in a straight line while lying down.  She could walk a straight line in a heel to toe position without any problem and also bend on her knee and raise herself back without any difficulties. There was also the ability to stand still with her eyes closed, feet together and arm at the sides for 20 seconds with little to no swaying. The patient was able to feel the sensation on both sides of her body when touched at the same time. The first touches were done randomly using a toothpick while the second touches were done using a wisp of cotton ball. The patient’s ability to tell the direction of her big toe when it was moved up and down was also positive.

Patient’s tactile discrimination is intact, as the patient was able to sense touch. This was established by recognizing a paper clip placed on her hand while her eyes were closed. The ability to recognize a number written on her palm with her eyes closed was also noted and she could able to feel sensation on both sides of her body when touched at the same time too. Similarly, the patient had the ability to place her finger on the same location (spot) that I had touched. She also has a normal skin color according to her ethnicity.

The health education needs for the patient include injury and violence prevention and nutrition, exercise, and obesity prevention. Injury prevention has been selected since the patient started feeling pain after playing softball with her friends. The pain might have come as a result of muscle sprains and strains or injury from overuse. Woody Collins (2019) asserts that efforts should be taken on educating people on all phases of injury control, including acute care, prevention, and rehabilitation, in order to improve people’s safety, health, and quality of life. According to healthy people 2020, injuries are widespread in the society. This includes both those which are caused by acts of violence and the unintentional injuries. Injuries are classified among the top 15 killers in the United States (healthypeople.gov). They are the leading cause for disability among people of all ages regardless of race, sex or socio-economic status. Injuries have the ability to result to years of potential life lost, premature death, poor mental health, lost productivity and high medical costs. On most cases, effects of injuries spill over to close friends, family members, coworkers and the community at large. As a result, Woody Collins (2019) believes that most of the unintentional injuries can be prevented by taking a closer look at a family’s lifestyle, environment and risks involved. It is important to find problems early and respond quickly. In my current patient’s case, it is important to note that injuries are likely to occur when excessive stress is placed on muscles, bones and ligaments. As a result, before indulging in sporting activities it is important to perform careful stretches, warm up in order to increase blood flow and use proper equipments among other things.

Education on nutrition, exercise, and obesity is recommended given that the patient has a BMI of 25. This is considered as being overweight and going further in this direction is not good for her health. According to Smith et al. (2017), people ought to receive sufficient education on poor dieting, sedentary behaviors, and physical inactivity since they spearhead the onset of obesity, which later results in unwanted health conditions. Obesity can be attributed to energy imbalance in the body where there are many calories coming in, but very few are being burned. The amount of activity that an individual is involved with on a daily basis determines how much calories one gets to burn. Indulging in exercise is one way of achieving this aspect. However, despite the health benefits that comes with physical exercise, people are doing less of it. The aspect has resulted to increasing cases of obesity to the extent that it has been declared an epidemic in the United States. Obesity can also be prevented through intake of desirable nutrition. Among the eating habits that people can implement in order to avoid obesity there is reduction of sugar consumption, avoidance of processed food, skipping saturated fats, limiting artificial sweeteners and eating more servings of fruits and vegetables among other things. Smith et al. (2017) assert that working to prevent obesity is a good thing as opposed to trying to fight it when it has already manifested given that it is associated with chronic health conditions. Among the conditions there is high blood pressure, metabolic syndrome, type 2 diabetes, sleep apnea, stroke, and heart disease  among others.

Physiological, cultural, developmental, and psychosocial factors will have an effect on the effectiveness of the proposed health education. Psychosocial factors such as stress, depression, and hopelessness might hinder the patient on aspects related to nutrition and exercise hence resulting in aspects of obesity (Gilbert & Sawyer, 2015). On cases when an individual has stress or aspects of hopelessness, there is no desire to improve one’s life. Regardless of how things turn out, this is not a problem since there is a mentality that greatness cannot be achieved. There are other people who tend to eat more when they are stressed. This is done without minding the nutritional value of the foods being ingested. As a result, being in such emotional status would easily result to increased probability of obesity. Physiology might also make it difficult for her to prevent injuries based on the way that her body functions. According to Peterson & Renström (2016), neglecting physiological processes when a tissue is injured can easily lead to inappropriate therapeutical interventions, which in turn are followed by unfunctional regeneration.

Ideas relating to customs and social behavior might also be a barrier to these education needs since they encompass the social determinants of health. These includes things like childhood experiences, coping skills and social support, access to nutritious food, and communication capabilities among others. On the other hand, an individual’s strength and collaborative resources can have a positive impact on education needs. Family and friends can be a good support system for someone that is into dieting and exercise. These are people that want the best for someone hence are willing to give that needed push in order for there to be positive results. To some extent, some friends and family members are likely to indulge in the same education needs and program so as to act as the support system. Furthermore, in case there are any detrimental mental health outcomes, they would be inconvenienced in several ways when taking care of the affected individual (Peterson & Renström, 2016). Health and wellness resources are also good sources of how to do what is required appropriately. People might have the information but end up implementing it inappropriately hence not getting the desired results.

By reflecting on this assignment, I can ascertain that physical examination and the assessment of health history are important in determining a patient’s general status of health and ensure that comprehensive care is provided to patients. In this case, the patient was friendly hence making it easy to establish a rapport. Establishing good rapport with a patient is important since it helps to establish a connection, which in return results to improved patient care. This is because there is the ability to understand a patient’s feelings that results to enhancing effective communication (Gilbert & Sawyer, 2015). The patient in this case was very open to answering all the questions that were directed to her. She did not show any hesitation and was audible throughout.  Her ability to maintain eye contact also made it possible for the observation of nonverbal cues

I can say that the whole experience goes hand in hand with what I have learned and was expecting. This is more so evidenced in my interaction with the patient. On obtaining the patient’s family medical history, it was evident that there was no history of chronic diseases. The expectation is that for this patient, the case would be the same, and that is exactly how it was. An individual’s genetic makeup tends to determine their risk of developing health problems (Daaleman & Helton, 2018). There were no communication barriers encountered in this particular case.  This is because there were no time constraints, the patient was not in severe pain or fatigue, and the patient was very open in providing the desired information. This aspect made the assignment to proceed well. The more information that a patient can provide, the easier it is to assess where the issues are. All the information that I deemed necessary was readily available. However, I would alter my approach in obtaining health history in the future to ensure that I can obtain more information regarding the patient’s cultural, developmental, and psychosocial considerations and also sources of collaborative resources. This because these aspects are critical for enabling the patient to institute the prescribed educational needs appropriately and effectively.

References

Daaleman, T., & Helton, M. (2018). Chronic Illness Care: Principles and Practice. Springer.

Gilbert, G., & Sawyer, R. (2015). Health Education: Creating Strategies for School & Community Health. Sudbury: Jones & Bartlett Learning, LLC.

Injury and Violence Prevention | Healthy People 2020. (2020). Retrieved 13 April 2020, from https://www.healthypeople.gov/2020/topics-objectives/topic/injury-and-violence-prevention

Kauffman, M. (2014). History and physical examination: A Common Sense Approach. Burlington, MA: Jones & Bartlett Learning.

Peterson, L., & Renström, P. (2016). Sports injuries: Prevention, Treatment and Rehabilitation, Fourth Edition. Taylor & Francis.

Smith, T. et al. (2017). Improving Nutrition and Physical Activity Policies and Practices in Early Care and Education in Three States, 2014–2016. Preventing Chronic Disease, 14.

Woody Collins, J. (2019). Achieving engagement in injury and violence prevention research. Injury Prevention, 25(5), 472-475. doi: 10.1136/injuryprev-2019-043257