Clinical Reasoning and the Physical Assessment
Chief complaint
Mr. F.K is a 32-year-old male who came to the clinic with complaints of fatigue, fever, and muscles aches.
The history of presenting illness provides details about the chief complaint in terms of onset, location, duration, alleviating and aggravating factors and any treatments tried (Craven, Hirnle & Jensen, 2013). F.K was in good health until two days ago upon arrival from a trip to Mexico when he noted that he had gradually increasing fever accompanied by fatigue and muscle aches. The muscle ache and fatigue were worsened by an increase in physical activity and reduced by rest. F.K complains of fever which he measured at 39oCelsius and took ibuprofen 600mg but no improvement was noted. Today he reports that he is experiencing chills and the fatigue and muscle aches are getting worse. He also states that he has some nausea and slight abdominal cramping.
The past medical history is a history of any past illnesses which the patient suffered from, any medications and allergies. It also includes surgeries ever done to the patient (Potter et al, 2016). Mr. F.K is suffering from hypertension which was diagnosed two years ago. He suffered from chicken pox in his childhood and no other major illness. He is currently under HCTZ 25mg daily for the treatment of his hypertension. Mr. F.K had a surgical operation at the age of one year for the repair of a bilateral inguinal hernia. He also experienced a broken arm at the age of eleven years and was hospitalized during the incidence of this injury and the surgical repair. His recent immunizations are tetanus injection that he acquired six years ago when he sustained a cut in his lower leg. He is allergic to sulfa which manifests as hives.
The family history is a summary of the family tree to determine any chronic and genetic illnesses to which the client might be predisposed to(Wilkinson et al, 2016). Mr. F.K’s maternal grandmother died at the age of 78 due to the unknown cause while the maternal grandfather sustained a heart attack at the age of 85. The paternal grandfather died from hypertension at the age of 76 years and the paternal grandmother died from osteoarthritis at age 80. His father is 55 years and suffering from hypertension while his mother is 50 years old with no chronic condition. Mr. F.K has a brother and a sister aged 26 and 21 respectively who are alive and well. There is no history of diabetes mellitus, cancer, and alcoholism, psychiatric and known genetic illness in the family.
Social history entails the social aspect of the client in terms of education, income, hobbies, marriage, residence, drinking and smoking habits (Craven, Hirnle & Jensen, 2013). Mr. F.K was born in East Orange, Essex County, New Jersey and has a baccalaureate degree in economics and statistics from Weston University. He currently works in a bank in the same area and has been married for 2 years with a daughter. In a typical day, he works in the bank for eight hours and attends evening classes for two hours. Mr. F.K is not a vegetarian and does not report allergy to any food component. His primary diet is composed of rice, beans, meat, vegetables, and fruits. Mr. F.K believes that his food and water are clean as they are prepared from his house save for the ones he took outside the home. He reports that he sleeps for at least six hours every night and likes jogging, cross country skiing, and sailing. He reports that he does not take alcohol or recreational drugs neither does he smoke cigarettes. His wife is also working to help cater for the family needs. Mr. F.K has recently traveled to Mexico for a business trip.
Review of systems refers to the systematic evaluation of the various body systems based on the information provided by the client (Wilkinson et al, 2016).Mr. F.K reports that he is generally in pain, with muscle pain and body weakness. He does not have any rashes, pruritus, skin or hair changes. There is no pain, redness or dryness of the eyes while rhinorrhea and sinus tenderness is also absent. Mr. F.K reports absence of pain and ringing in the ears and the sense of hearing is intact. The client does not have a cough and hemoptysis, no chest pain, murmurs or palpitations. He reports the absence of easy bruisability, anemia or transfusions. Mr. F.K reports that he breathes normally and does not have any problems with respirations. Mr. F.K does not have changes in bowel movement but he is experiencing nausea and some slight abdominal pain. In the genitourinary system, there is the absence of urinary urgency, pain, and hesitancy. The client has a hernia in infancy that as repaired and he does not have testicular pain. The client reports that he does not have discharge or sores in the genitalia neither does he experience the sexual problem. He has muscle pain and fatigue with no history of seizures and fainting.
Findings
Mr. F.K could be suffering from typhoid fever which is characterized by fever, muscle pain, and fatigue. He also reports having some slight nausea and some abdominal cramping which are signs of typhoid fever. His recent travel to Mexico which is a region with high prevalence of typhoid also supports the possible diagnosis (Buckle, Walker & Black, 2015).
References
Buckle, G. C., Walker, C. L., & Black, R. E. (2015). Typhoid fever and paratyphoid fever: Systematic review to estimate global morbidity and mortality for 2010. J Glob Health. 2012; 2 (1): 010401. Clin Microbiol Rev, 28(4), 901-37.
Craven, R. F., Hirnle, C. J., & Jensen, S. (2013). Fundamentals of nursing. Wolters Kluwer Health/Lippincott Williams & Wilkins,.
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of Nursing-E-Book. Elsevier Health Sciences.
Wilkinson, J. M., Treas, L. S., Barnet, K. L., & Smith, M. H. (2016). Procedure Checklists for Fundamentals of Nursing. FA Davis.
