Paper Info
| Page count | 2 |
|---|---|
| Word count | 929 |
| Read time | 4 min |
| Topic | Health |
| Type | Assessment |
| Language | 🇺🇸 US |
- Progress Notes: Patient’s Name: Mrs. White
- DOB: 12-08-76
Appl. /TPO Assignment: TPO-4-1 The Anxious Patient.
| Date | Allergies: Aspirin | Initials |
| 3/26/21 4.00 PM | The patient came to the clinic for her annual physical check-up. However, the patient appears to be fidgeting in her seat, evidenced by repetitive pacing movements. | |
| The patient has rapid breathing rates and appears sweaty. She admits to being fearful of the uncertainty of the physical examination findings. | ||
| I reassured the patient that there was nothing to be wary of in the physical examination. I informed her that any abnormal findings would provide a framework for the treatment plan. | ||
| I also told her that the healthcare professional was very competent in conducting the physical examination. The patient appeared relaxed after my reassurances. | ||
| I assured the client that I would be there to assist the PCP during the procedure. The patient inquired to know whether an intramuscular injection would be conducted. | ||
| I informed her that the intramuscular injection would be for the administration of an analgesic drug for pain. She verbalized her fears about getting muscle paralysis from the injection. | ||
| I informed her that the PCP would follow the standard protocols for administering intramuscular injections. The PCP will give the injection at the gluteus muscle’s outer quadrant to avoid injuring the sciatic nerve. | ||
| I informed her that the healthcare personnel would ensure that they do not inject the sciatic nerve. | ||
| Furthermore, I informed the client that I would talk to her during the entire procedure to act as a distraction to relieve pain sensations—————— | CM. | |
| 8:55 AM | I notified the PCP that she was anxious for the exam and intramuscular injection and that I had reassured her——————————————————————– | CM. |
| 9:10 AM | The PCP completed the physical examination and the intramuscular injection. The patient verbalized satisfaction about the procedure and promised to be less anxious during the next check-up………………………………………….. | CM. |
- Progress Notes:
- Patient’s Name: Felicia Tim
- DOB: 10-6-60
Appl. /TPO Assignment: TPO-4-2 The Angry Patient.
| Date | Allergies: Tetracycline | Initials |
| 3/26/21 | The patient came to the facility for her monthly check-up for diabetes and hypertension. He expressed his displeasure about the nurse having to conduct a physical examination on him. | |
| 3.00 PM | He says that his problem was about blood sugars and nothing else. He appears visibly irritated about being admitted into the hospital. | |
| I encouraged him to relax by deep breathing. | ||
| I explained to him the need for the head-to-toe check-up to identify any complications from diabetes, including edematous legs (Jarvis, 2018). | ||
| I also informed him that he was required to be admitted for the prompt management of the elevated blood sugars. | ||
| I explained that unmanaged high blood sugars and high bold pressures had detrimental effects on his health, including vision disturbances. | ||
| I utilized good communication skills and maintaining eye contact during the interactions. | ||
| The patient appeared relaxed after this intervention. | ||
| The patient consented that the PCP conduct the physical examination. | ||
| He also agreed to change into the hospital gowns for admission into the ward to manage the high blood sugar and high blood pressure. | ||
| The patient felt relieved and thanked me for addressing his concerns. | ||
| The patient had no questions for me. | C.M. | |
- Progress Notes:
- Patient’s Name: Tim Wern
- DOB: 12.12.1984
Appl./TPO Assignment: TPO-4-3 The Interpreter.
| Date | Allergies: Ibuprofen | Initials |
| 3/31/21 5.00 PM | The patient came for a physical examination accompanied by an interpreter. A review of his chart shows he is from Tanzania and speaks minimal English————- | |
| I introduced myself to the client and the interpreter | ||
| I inquired from the interpreter of any cultural factors I needed to consider during the physical examination. He assured me that there were none. | ||
| I introduced myself to the client and the interpreter in English while the interpreter translated my words to the client in Swahili. I informed them that I would be the PCP assistant liable for conducting the physical examination. | ||
| I asked the interpreter to ask the patient about his medication history. | ||
| The interpreter seemed to engage in an extensive discussion with the patient. Then, the interpreter informed me that the patient forgot his medications in his native country. | ||
| I inquired to know the identity of the drugs from the patient. The interpreter informed me that he was not sure, but he thinks they were two drugs for treating the joints’ inflammation. | ||
| The patient consented to obtain a chart from a local pharmacy. | ||
| The patient indicated that he would pick a chart from Downtown Pharmacy. | ||
| I informed the patient that we would call the patient with an interpreter to review the medications once the delivery was completed. | ||
| I asked the interpreter to inquire whether the patient understood the instructions. | ||
| I explained to the patient that he would need to undress and wear the hospital gown for the physical examination with the interpreter’s help. I informed them that the PCP would come in shortly to conduct the physical investigation. | ||
| I inquired whether the patient had any questions. The patient sought clarification on whether he would need to go back to his native home for his medications. I informed him that this was unnecessary as they would be replaced. | ||
| I informed the patient and the interpreter that I would be back to address their concerns. | ||
| I left and let the PCP know the patient was ready and had an interpreter——————————————————————- | C.M | |
| 3/31/21 3.45 pm | The PCP gave me the summary of the physical exam. I gave it to the interpreter to help the patient review the doctor’s findings and other directions. | |
| The patient verbalized an adequate understanding of the instructions through the interpreter and promised to follow up appointments for a medication review. | C.M. | |
Reference
Jarvis, C. (2018). Physical examination and health assessment-Canadian e-book. Elsevier Health Sciences.