Case Study: Analyzing John Walker's Health History and Assessments

This case study presents the health history of a 50-year-old male, John Walker, focusing on his medical conditions including arthritis, hypertension, and asthma. The assignment details his past medical and surgical history, current medications, and lifestyle factors such as smoking, alcohol consumption, and diet. The assessment incorporates nursing tools like X-rays and MRI to diagnose and monitor arthritis. The case study further explores the physiological, pathophysiological, pharmacological, epidemiological, and therapeutic aspects of his conditions, including normal versus abnormal values for various cues like blood pressure and uric acid. The patient's lifestyle choices, such as smoking and drinking, and their impact on his health are also discussed. The study emphasizes the need for regular monitoring and personalized care, highlighting the importance of general health assessments and problem-focused assessments in managing the patient's health effectively. The analysis includes a discussion on the patient's response to treatment and lifestyle modifications like yoga and meditation, which have helped manage his hypertension. This comprehensive case study aims to provide a thorough understanding of patient assessment, diagnosis, and treatment within a healthcare context.

Health History
Gender Male/Female
Female
Age 50
Current Medical History
What current medical conditions do
you have?
I am 50 years old male and I have many problems
related to health. The major health issue I am having
is arthritis. It causes pain, restriction in moving and
inflammation. Because of this my joints are weak. I
have also hypertension and due to this my blood
pressure in arteries is constantly elevated. Also I have
asthma since childhood. This causes problem in
breathing sometimes.
Past Medical/Surgical History
What is you past medical/surgical
history?
Medical History
I have operated once for minor heart
Surgical History
There was laser therapy for kidney
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attack. This resulted in weakness
and breathing problem.
stone before 9 years.
Medications
What medications do you take?
List medications and dosages (where
possible)
For arithritis person is taking the following
medications -
 Analgesics, such as hydrocodone (Vicodin) or
acetamonophen (Tylenol) for getting relieve
from pain.
 Nonsteroidal anti-inflammatory drugs
(NSAIDs), such as ibuprofen (Advil) and
salicylates as this helps in help controlling
pain and inflammation (Briggs, Rethman, &
Lopez, (2018). Salicylates help in thinning
blood.
 Menthol or capsaicin creams for blocking the
transmission of pain signals from the joints.
 Immunosuppressants like prednisone or
cortisone for reducing inflammation.
Also hypertension the patient takes medicines like
Bumetanide (Bumex) and Chlorthalidone (Hygroton)
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Do you live alone/with
someone?
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 Yes
Yes/No No
Yes/No No
Yes/No No
Do you have a vision impairment?
Do you wear glasses?
What type of glasses are they?
Yes/No Yes
Yes/No
Do you have a hearing impairment?
Do you wear a hearing aid?
Which ear do you wear them in?
Yes/No No
Yes/No No
Right ear/Left ear/both
Do you wear dentures?
Are they upper/bottom dentures?
Yes/No No
Upper/bottom/both
Do you drink alcohol?
How often do you drink?
How many drinks do you have each
day?
Yes/No Yes
Drink is consumed once in a month
Do you smoke?
How many cigarettes do you smoke
a day?
Yes/No yes
3 – 4
Do you follow a special diet?
What is the special diet?
Yes/No Yes
Balanced diet is consumed which includes
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What is your height?
What is your weight?
pulses, roughage and carbohydrates. The
main focus is on iron rich food items.
5 feet 8 inches
80 Kg
Do you have any mobility issues?
Do you use a mobility aid?
What mobility aid do you use?
Do you do any exercise?
Yes/No Yes
Yes/No No
Yes. Yoga is done every morning
Do you have any wounds?
Where are they?
Yes/No No
1) Nursing assessment tool used – Result - Laboratory tests are included in treatment
of arthritis. Fluids form body is taken for for
analysing and these fluids includes joint fluid, blood
and urine. Imaging is used is an assessment used in
arthritis patient. The imaging test helps in detecting
various problems with joints Byrd, May, & Marsden,
(2017). Some of these are X-rays, computerised
tomography (CT) and Magnetic resonance imaging
(MRI).
X -rays – In this type of treatment, low level of
radiation is used for visualising bones. X-ray shows
cartilage bone, bone spurs and bone damage. X-ray is
used for tracking progression of arthritis in patient.
2) Nursing assessment tool used
–
Result -
Computerised tomography (CT) – The CT scanners
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are used for taking X-rays from various angles and
combining the information for creating cross sectional
views of internal structures. The patient's bones and
surrounding soft tissues are visualised through this
tool.
3) Any other nursing assessment
tools used -
Result –
Magnetic resonance imaging (MRI) – This is a tool
used for getting more detailed cross sectional images
of soft tissues like tendons, cartilage and ligaments.
This tool combines radio waves with strong magnetic
field and helps in analysing more effectively.
Any other information you wish to add
in relation to the person you
interviewed.
The patient requires regular analysis as it will
help in knowing what the progress in arthritis.
This individual shared that doing meditation and
yoga daily has helped a lot in reducing problem
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of hypertension. This patient is recovering from
the problem of joint pain effectively.
Assessment 1 – Case Study Template
1) Consider the Individual (25 words)
The patient's name is John Walker and he is 50 years old. He started having pain in his knees at the age of early 40's. This person had some
bad habits including smoking and drinking which affected his health to a greater extent and currently he is having problem of arthritis and
hypertension.
2) Collect cues/Information
Current information- including your 2 assessments: (cues collected during the interview) (250 words)
X-ray helped in getting two dimensional picture of joint of the patient. These show joint space narrowing, fractures, erosions, bone spurs and
bone density. These are easily available and affordable by all patients. These are the first imaging technique used for assessing osteoarthritis.
These also help in knowing which part of the body is damaged.
MRI provides a 3- Dimensional image of bones, soft tissues and bones by the use of magnetic field and pulses of radio waves. This shows
tears in soft tissues as well as infection. MRI helps in getting more detailed information related to arthritis joint.
The patient was diagnosed arthritis in the year 2010 and since then the patient is not able to live his life happily. He was having problem in
doing daily activities like bathing, moving, walking etc. After having proper treatment and medication, the patient started to recover and stable
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his life. Now the patient is recovering fast and maintaining stability in his life.
Gather new information: (identify 3 other assessments that you could conduct regarding this person and the
importance of these assessments) (200 words)
General health assessment – This is nursing health assessment which is valuable tool for nurses. This provides a thorough and skilled
assessment and it provides the nurses for obtaining descriptions regarding symptoms of patients, how systems are developed and process for
discovering any physical findings which helps in development of diagnosis. This assessment includes both objective and subjective data. This
provides an opportunity for individuals Gummesson, Sundén, & Fex, (2018). Problem focused assessments – This is caused when an interval
assessment shows change in aspect from present assessment or report. The main benefit of this is that it directs for asking about symptoms and
conducting a focused physical exam.
Recall (using literature identify and describe 3 cues in relation to physiology, pathophysiology,
pharmacology, epidemiology, therapeutics, contexts of care or ethics that will assist you to further
understand this personal health) (300 words)
Physiology – The main physiological cues includes person finds it difficult to move joints become stiff. Other factors are person is not able to
do daily activities effectively.
Pathophysiology -
Arthritis causes tiredness and loss of appetite is also there because of inflammation of immune system. Patient becomes anaemic and red
blood cells decreases.
Pharmacology -
Painkillers. These medications help reduce pain, but have no effect on inflammation. An over-the-counter option includes acetaminophen
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(Tylenol, others)
Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce both pain and inflammation. Over-the-counter NSAIDs include ibuprofen
(Advil, Motrin IB, others) and naproxen (Aleve)
Disease-modifying antirheumatic drugs (DMARDs). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system
from attacking your joints.
Epidemiology -
The different way for preventing arthritis are Osteoarthritis – Maintain a healthy weight, Rheumatoid arthritis – Do not smoke and Gout – Eat
a healthful diet, low in sugar, alcohol and purines
Therapeutics - The different type of therapies given to patient are listed below -
Physical therapy is used for treatment of arthritis. Various exercise help in improving range of motion and building strong joints.
Joint repair surgery is smoothed for reducing pain and improving the functions.
The joint fusion therapy is also considered for removing ends of bones in joint.
3) Process information
Interpret –(Identify the normal versus abnormal values of 5 cues collected during the assessment and
describe your client/patients assessment/history results) (100 words)
Cues Normal/ Abnormal value
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Blood pressure The blood pressure of patient is relatively
higher than normal rate.
More than normal rate
Anti cyclic citrullinated peptide (anti – CCP) This is also known as anti citrullinated protein
antibodies(ACPA). This is a test for arthritis
which looks for presence of auto antibody in
the patient’s body. The presence of anti –
CCP reflects the presence of rheumatoid
factor.
This is present in patient's body.
Uric acid The level of uric acid in blood helps in
diagnosing gout. This is a condition which
occurs when uric acid crystallises and
deposits are formed in joints and tissues.
There is presence of uric acid in patient's
body.
Erythrocyte sedimentation rate This is also known as ESR and this is helpful
in measuring the rate at which red blood cells
cling together LaRochelle, Dong, & Durning,
(2015). If the rate of sed is higher, the amount
of inflammation will also be more.
The patient is having high rate of sed present
in body
Joint fluid tests In this test, needle is inserted into joint space There is presence of crystals of uric acid.
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and fluid is removed. The testing of fluid
reveals crystals of uric acid and this diagnose
gout. Bacteria present in fluid explains the
reason for joint inflammation.
Discriminate – (Identify the two most important results/cues and why you consider they are important) ( 150
words)
Erythrocyte sedimentation rate – This is a type of blood test which measures the rate at which red blood cells settle at bottom of test tube
which contains sample of patient’s blood. For a normal individual, the rate of settling of these cells is relatively slower. But when there is
faster rate of settling of these then this reflects inflammation Laverentz, & Kumm, (2017). This is important as it will help in knowing the
reason of inflammation in patient who is having problem of arthritis. It will also help in providing right kind of treatment to patient.
Anti cyclic citrullinated peptide (anti – CCP) – This is an antibody present in patients having arthritis. The various levels of anti – CCP are
detected by blood sample. If the test is positive, result can be used in conjunction with any other blood test, physical examination or imaging
tests. The positive test can be used in determining severity of symptoms. This is important as it helps in initiating right kind of treatment to
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arthritis patient.
4) Identify
problems/issues (50
words)
What is the issue for the
patient/ individual?
5) Establish Goals ( 50
words)
What do you want to achieve
as an outcome?
SMART Goals
6) Take Action ( 100
words)
What will you do here in the
way of care for the
patient/individual?
7) Rationalise your
nursing action
(300 words total)
Why have you chosen the
actions you want to do for
the patient/individual?
With references to support
your rationales
First Nursing Problem
The patient was having problem
in doing daily activities like
yoga, walking, stretching and
activities which includes moving
of joints.
One Nursing Goal -
The main objective of nurse of this
patient is to help that person move
and reduce pain and quality of his
life.
First action –
The first action taken by nurse for
achieving this goal is occupational
and physical therapy to the person.
Other cold therapies, acupuncture,
meditation, massage, heat therapy
and providing relaxation therapy
Rationale -
The nurse chose occupational
and physical therapy as it is
very helpful in treating people.
The patient is having stiff
joints and this pain gets worse
with time. Thus, physical
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therapy is needed for teaching
the person how to work out
stiffness and not damaging the
joint further.
Second action – The second
action as a nurse taken is to
provide pharmacologic therapy
Scaddan, Rowell, & O’Leary,
(2017). This includes the following
medications as per the diagnosis of
patient.
NSAIDs. COX-2 – These
medicines block the enzyme
involved in inflammation while
leaving intact the enzyme involved
in protecting the stomach lining.
Methotrexate. Methotrexate is
currently the standard treatment of
arthritis because of its success in
preventing both joint destruction
Rationale -
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and long-term disability.
Analgesics. Additional analgesia
for periods of extreme pain.
Second Nursing Problem
Another problem faced by nurses
with patient of arthritis is
deficient knowledge. This
includes deficiency or absence of
cognitive information associated
with arthritis. This may be due to
lack of exposure and information
misinterpretation.
One Nursing Goal -
The main objective of nurses is to
develop knowledge regarding
arthritis and know how to plan for
self care regarding lifestyle
modifications and activity
restrictions.
First action –
The first step taken by nurse is to
create knowledge about arthritis
and know what are the different
problems faced by individuals
having arthritis. The patient has to
understand therapeutic needs. Also
self care plan is developed. The
reviewing of disease process,
prognosis and future expectations
are examined.
Rationale –
The reason behind choosing
this is that this helps in
grabbing knowledge base
from which patients are able
to make informed choices.
The main objective of disease
goal is to suppress
inflammation in joints and
other tissues for maintaining
joint function and preventing
deformities.
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Second action –
Assisting in planning for realistic
as well as integrated schedule for
rest, activities, drug administration,
personal care, stress management
and physical therapy .Wolfinger,
& Davenport, (2016).
Rationale –
This helps in providing
structure and defusing anxiety
when managing this complex
chronic disease.
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8) Reflect on process and new learning ( 250 words)
While doing the health assessment, I learnt many new ways of treating patients. Reflection is the last stage of clinical reasoning cycle. I get to
know about different phases of clinical reasoning cycle. First of all the main thing is to consider all facts related to the medical history of
patient. I received all the information and current medical status of my patient. In the next step, the past medical history of patient, current
treatment plan and vital signs are presented. I made my findings for physiology, culture, pathology, pharmacology and ethics for establishing
the cues and drawing information. The current health status of patient suffering from arthritis in respect to pathological and pharmacological
aspects is analysed. Also I got to collect information about treatment goals for situation of patient. Several action taken for treating the patient
are listed. For doing the health assessment, I interviewed my family relative uncle John and I was able to learn different phases of clinical
reasoning cycle by collecting information and data about him.
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Reference List
Briggs, M. S., Rethman, K. K., & Lopez, M. T. (2018). CLINICAL DECISION MAKING AND DIFFERENTIAL DIAGNOSIS IN A
CYCLIST WITH UPPER QUARTER PAIN, NUMBNESS, AND WEAKNESS: A CASE REPORT. International journal of sports
physical therapy, 13(2), 255.
Byrd, E., May, S., & Marsden, J. (2017). The sacroiliac joint: a qualitative assessment of current practice in the United
Kingdom. Physiotherapy, 103, e92-e93.
Gummesson, C., Sundén, A., & Fex, A. (2018). Clinical reasoning as a conceptual framework for interprofessional learning: a literature review
and a case study. Physical Therapy Reviews, 23(1), 29-34.
LaRochelle, J. S., Dong, T., & Durning, S. J. (2015). Preclerkship assessment of clinical skills and clinical reasoning: the longitudinal impact on
student performance. Military medicine, 180(suppl_4), 43-46.
Laverentz, D. M., & Kumm, S. (2017). Concept evaluation using the PDSA cycle for continuous quality improvement. Nursing education
perspectives, 38(5), 288-290.
Scaddan, E., Rowell, J., & O’Leary, S. (2017). A preliminary case series evaluating the safety and immediate to short-term clinical benefits of
joint mobilization in hemophilic arthritis of the lower limb. Journal of Manual & Manipulative Therapy, 25(4), 208-214.
Wolfinger, C. R., & Davenport, T. E. (2016). Physical therapy management of ice hockey athletes: from the rink to the clinic and
back. International journal of sports physical therapy, 11(3), 482.
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