Health Assessment Case Study: John Wells - Analysis and Evaluation

This case study focuses on the health assessment of John Wells, an 82-year-old dairy farmer who experienced an accident. The assessment includes the patient's chief complaints of nausea, headache, fatigue, and loss of appetite, along with his past medical history of hypertension. The document details the collection of subjective and objective data, including vital signs, pain assessment, and the use of the Glasgow Coma Scale (GCS) and PERRLA to evaluate potential head injury. The analysis processes the information, linking the patient's symptoms to his hypertension and the accident, and discussing the potential impact on the brain. The case study references relevant literature to support the analysis and conclusions regarding John Wells' condition.

Running head: HEALTH ASSESSMENT
HEALTH ASSESSMENT
Name of the student:
Name of the university:
Author note:

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HEALTH ASSESSMENT
Consider the patient’s condition:
The patient is 82 year old man who resides in the rural part of the country. He has been
admitted to the hospital due to chief complaints of nausea, headache, fatigue, hazy and loss of
appetite. By interviewing the patient, it is identified that the patient recently had an accident from
bike. The patient became unbalanced and fell down striking left side of his head to the ground.
The patient witnessed minor skin tear on his left forearm and minor abrasion to the left elbow.
During assessment the patient denies any pain, injury or stiffness and also does not experience
any stiffness or reduced movement to the chest, limbs or neck. The patient has a past medical
history of hypertension, but he has not been prescribed to any hypertensive drugs. The patient
does not have any past medical history of brain injury or concussion.
The chief complaints observed in the case of john (patient), is the nausea, headache,
fatigue, hazy and loss of appetite. It is observed that severe headache can cause loss of appetite
into the patient. According to Jensen, Radojicic and Yri (2016), the risk factor behind headache
in the case of john could be brain injury due to the accident he met recently or hypertension.
Apart from this, the other chief complaints of the patient such as, fatigue, hazy, lightheadness,
nausea and dizziness is due to the past medical history of the patient, which is hypertension, as
the patient stated that he does not take any anti-hypertensive medication.
Collect cues and information:
To get more clear information regarding the health condition of the patient, I will first collect
the subjective and objective data.

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The subjective data includes the symptoms of the disease experienced by the patient (Jun,
Cha and Lee 2015). The subjective data that has been collected from the patient includes,
1. Nausea
2. Headache
3. Hazy
4. Dizziness
5. Mild confusion
6. Fatigue
7. Loss of appetite
After collecting the subjective data from the patient, the objective data are also collected by
after proper assessment of the patient (Briesacher et al. 2019).
1. Body temperature : 36.7 degree Celsius
2. Blood pressure: 148/84
3. Pulse rate: 81 beat per minute
4. Respiratory rate: 17 breaths per minute
5. Oxygen saturation: 97% on the room air
6. Headache: pain 4/10
The body temperature of the patient (36.7 degree Celsius), the pulse rate of the patient (81
beat per minute), oxygen saturation (97% on the room air) and the respiratory rate (17 breaths
per minute) of the patient is normal. However, the blood pressure of the patient is 148/84, which
is high than that of the normal blood pressure (120/80) (Ochiai et al., 2015). The pain score of

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the patient is observed to be 4/10, which means that the patient has been suffering from moderate
pain.
The patient is also assessed with the help of glass coma scale to evaluate the level of
consciousness among the patient. Glass coma scale is used for the assessment of the patient’s
consciousness especially if the patient had any brain injury (Glaser et al., 2016). In this case,
john recently had an accident hence; I will go for the GCS to assess the mental condition of the
patient. The consciousness of the patient is assessed by GCS in the terms of score between the
range of 3 and 15. 3 is considered as the worst and the patient is considered to have low
conscious level and have low eye response, low verbal response and low motor response and if
the GCS score of the patient is 15, the patient is considered to have best motor response, best eye
response and best verbal response.
During the accident, the head of the patient hit hardly to the ground, hence it is important
to conduct test to ensure that the patient does not have any cranial injury. Hence in order to do
that, pupillary response test or PERRLA is performed (Lynch et al. 2015). This test helps to
evaluate the cranial injury by assessing the dilation of the pupil.
The patient has experienced tear in the left forearm and left elbow which might be
responsible for the pain. In order to evaluate that, I will perform pain assessment of the pain by
the help of pain assessment scale (Kochman et al. 2017).
As the left side of the brain of the patient got hit by the ground, there is possibility that
the patient’s cognitive memory has been affected. There, to ensure that cognition test has been
performed. Apart from that different test are also performed to evaluate the co-ordination,
accuracy and balance of the individual, which might be possibly effected during accident.

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The vital signs and the neurological assessment are performed at regular interval to keep
the record of the patient’s physical and mental health condition.
Process the information:
This step of the clinical reasoning helps to process the information collected in the above
step. From the above, it is observed that the patient is feeling dizzy and hazy. The major cues
collected in the case of john is the past medical history of the patient is of hypertension and by
assessing the vital signs also, it is observed that the blood pressure of the patient is much higher
(148/84 mmHg) than the normal blood pressure (120/80 mmHg), confusion, fatigue, dizziness
and headache. In the case of high blood pressure, extra pressure has been exerted on the brain
and affects the blood-brain barrier and leads to headache. Another chief complaint of the patient
is that, he gets tired very easily, which is due to the hypertension. As fatigue one of the major
symptoms of the hypertension. In the case of hypertension, the work of the heart increases due to
which the heart demands for more oxygen rich but is not able to maintain the blood flow
resulting to fatigue (Matura et al. 2016). The other symptoms observed in the patient, that is
nausea, confusion and loss of balance and dizziness is primarily occurs due to medication
prescribed for the blood pressure, not because of the high blood pressure. In the patient, loss of
appetite is also observed which is due to the high blood pressure. Therefore in the case of john, it
can be stated that other symptoms of the patient is due accident. In the accident, the left
hemisphere of the brain had hit the ground. The left hemisphere of the brain is responsible for the
logical knowledge of the individual (Hart et al. 2018). When the blood-brain barrier or the blood
flow of the brain is affected, it leads to confusion and other co-ordination complications. Along
with that, the patient is also suffering from moderate pain, which is due to the skin tear and
abrasion in the left forearm and elbow. During an injury, the peripheral pain receptor is activated

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and along with it, the specific A delta and nociceptors are activated which leads to sensation of
pain and it is also responsible for the increased blood pressure of the patient (Colloca et al.
2017). Hence, from the above discussion, it can be summarized that the chief complaints
observed in the case of john is due to the high blood pressure and injury caused due to the left
elbow, forearm and brain.

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References:
Briesacher, B.A., Mui, B., Devlin, J.W. and Koethe, B., 2019. Nursing homes underreport
antipsychotic prescribing. Aging & mental health, pp.1-5.
Colloca, L., Ludman, T., Bouhassira, D., Baron, R., Dickenson, A.H., Yarnitsky, D., Freeman,
R., Truini, A., Attal, N., Finnerup, N.B. and Eccleston, C., 2017. Neuropathic pain.
Nature reviews Disease primers, 3, p.17002.
Glaser, J., Vasquez, M., Cardarelli, C., Galvagno, S., Stein, D., Murthi, S. and Scalea, T., 2016.
Through the looking glass: early non-invasive imaging in TBI predicts the need for
interventions. Trauma surgery & acute care open, 1(1), p.e000019.
Hart, S., 2018. Brain, attachment, personality: An introduction to neuroaffective development.
Routledge.
Jensen, R.H., Radojicic, A. and Yri, H., 2016. The diagnosis and management of idiopathic
intracranial hypertension and the associated headache. Therapeutic advances in
neurological disorders, 9(4), pp.317-326.
Jun, W.H., Cha, K.S. and Lee, K.L., 2015. Factors affecting subjective well-being in nursing
students. J Korean Acad Soc Nurs Educ, 21(2), p.276.

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Kochman, A., Howell, J., Sheridan, M., Kou, M., Ryan, E.E.S., Lee, S., Zettersten, W. and
Yoder, L., 2017. Reliability of the faces, legs, activity, cry, and consolability scale in
assessing acute pain in the pediatric emergency department. Pediatric emergency care,
33(1), pp.14-17.
Lynch, G., James, S.M., VanDam, M. and Potter, N.L., 2015, May. Facial response to visual
stimuli: using pupil response as an indicator of phenotype in ASD. In Annual Meeting of
the International Society of Autism Research (IMFAR), Salt Lake City, UT.
Matura, L.A., Shou, H., Fritz, J.S., Smith, K.A., Vaidya, A., Pinder, D., Archer-Chicko, C.,
Dubow, D., Palevsky, H.I., Sommers, M.S. and Kawut, S.M., 2016. Physical activity and
symptoms in pulmonary arterial hypertension. Chest, 150(1), pp.46-56.
Ochiai, H., Ikei, H., Song, C., Kobayashi, M., Takamatsu, A., Miura, T., Kagawa, T., Li, Q.,
Kumeda, S., Imai, M. and Miyazaki, Y., 2015. Physiological and psychological effects of
forest therapy on middle-aged males with high-normal blood pressure. International
journal of environmental research and public health, 12(3), pp.2532-2542.