Health History - Case Study Template

Health History
Gender Male
Age 40
Current Medical History
What current medical conditions do you
have?
He is associated with urinary tract infection (UTI) with severe suprapubic pain and fever. He is
associated with reduced urine output and increased urgency.
Data related to his vital signs and other clinical symptoms which was collected from his case reports:
RR 23, Sats 94% on RA,
Circulation: HR 95 bpm,
BP 176/100 mmHg,
He described his pain as achy, burny and gripping. His daytime frequency is 11-13 and nocturia is 4-
5voids.
Dark-colored urine.
Past Medical/Surgical History
What is you past medical/surgical history?
Medical History
T2DM, Ex-smoker (5 years before), HTN,
Hyperlipidaemia, chronic kidney disease stage
3 (Baseline eGFR 40 ml/min/1.73m2), chronic
venous leg ulcer to L) leg, anxiety. No known
declared allergies (NKDA). He is obese (BMI
32) and drinks 1 bottle of wine every night.
He is using antimuscarinics, trimethoprim-
sulfamethoxazole, tricyclic antidepressants
Surgical History
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and oxycodone. He reported chills and fever.
He has had 2 prior UTIs in the past year,
which were successfully treated each time
with trimethoprim-sulfamethoxazole (TMP-
SMX) 160 mg/800 mg twice a day for 3 days.
The last UTI was 4 months ago which was
associated with pyelonephritis.
Medications
What medications do you take?
List medications and dosages (where possible)
He is administered with medications such as paracetamol (650 mg), oxycodone (20 mg extended
release tablets per day), metformin (500 mg every 12 hours) and captopril (25 mg PO q 8-12 hr).
Do you live alone/with someone? With someone
Are you able to care for yourself?
Do you need help with showering?
Do you need help with toileting?
Do you need help with dressing?
Yes
No
No
No
Do you have a vision impairment?
Do you wear glasses?
What type of glasses are they?
Yes
No
Do you have a hearing impairment?
Do you wear a hearing aid?
Which ear do you wear them in?
No
No
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Do you wear dentures?
Are they upper/bottom dentures?
No
Do you drink alcohol?
How often do you drink?
How many drinks do you have each day?
Yes
1 bottle per night
Do you smoke?
How many cigarettes do you smoke a day?
Ex-smoker
Do you follow a special diet?
What is the special diet?
What is your height?
What is your weight?
Yes
Diabetic diet
150 cm
75 kg
Do you have any mobility issues?
Do you use a mobility aid?
What mobility aid do you use?
Do you do any exercise?
No
No
Do you have any wounds?
Where are they?
Yes
1) Nursing assessment tool used – Result –
Anthropometric measurements method was implemented for Mr. John for the nutritional and dietary
assessment. Different parameters such as body weight, % body weight change, Mid upper arm
circumference, skin fold thickness, and Mid arm muscle circumference. Change in body weight is
directly proportional to the alteration in the fluid balance. In patients with UTI, chances of sudden
change in body weight are high attributable to fluid loss due urine output and vomiting. Alteration in
body fluid is also responsible for Skin fold thickness. Skin fold thickness can be assessed using
calibrated skin fold calliper and it can be considered as surrogate marker of fat mass (Fryar, Gu,
Ogden, and Flegal, 2016; Gavriilidou, Pihlsgård, and Elmståhl, 2015).
2) Nursing assessment tool used – Result – Pain assessment was performed for Mr. John using PQRST algorithm. Pain assessment is
one of the significant factors for him because patients with UTI are usually associated with acute
pain. Pain assessment is also beneficial in planning early intervention and prescribing appropriate
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analgesic for pain management. PQRST algorithm comprises of questions such as P =
Provocation/Palliation, Q = Quality/Quantity, R = Region/Radiation, S = Severity Scale and T =
Timing. Pain assessment for Mr. John was performed at multiple time points and average was
considered for interpretation because PQRST algorithm is based on the subjective parameters.
Henceforth, physical and psychological condition of patient might alter the pain assessment. It has
been observed that pain assessment in Mr. John was consistent at different time points of the day.
Pain was recorded as 8 on scale of 0-10 for Mr. John which can be considered as the severe pain
(Varndell, Fry, and Elliott, 2017).
Assessment 1 – Case Study Template
1) Consider the Individual (25 words)
According to Levett-Jones et al. (2014), this is the initial stage of clinical reasoning cycle. During this stage, nurse interact with patient to
understand past and present clinical condition of the patient.
2) Collect cues/Information
Current information- including your 2 assessments: (cues collected during the interview) (250 words)
Cues from the nutritional and dietary assessment and pain assessment were collected during the interview. Patients with nutritional imbalance might
be associated with excessive energy intake and obesity which can lead to hypertension. Information about hypertension in Mr. John was gathered
from his anti-hypertensive medication which is captopril 25 mg PO q 8-12 hr. Captopril in beneficial in reducing hypertension to normal level.
However, it was observed that hypertension was not reduced in case of Mr. John after consumption of Captopril. In addition to this Mr. John was
exhibiting signs and symptoms of hypertension such as headache, fatigue, vision problem, and breathing difficulty. It is evident that acute pain is
responsible for exaggeration of hypertension (Saccò et al., 2013). Mr. John was also verbalised that he was experiencing amplified symptoms of
hypertension during pain episodes. HR also augment during augmented pain. Cues about pain were gathered from the administered analgesic
medicines. Oxycodone was being prescribed for Mr. John with the dose of 20 mg extended release tablets per day for the management of pain
(Gabayan et al., 2017). Cues about T2DM was gathered from the administered antidiabetic medication to Mr. John. Mr. John mentioned that he was
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