Individual Client Health History and Examination

INDIVIDUAL CLIENT HEALTH HISTORY AND EXAMINATION

IndividualClient Health History and Examination

Situation

Arthritisis a health condition characterized by the inflammation of jointsleading to pain and stiffness in the affected parts of the body(William, 2005). The patient started experiencing symptoms of thiscondition two months ago with soothing pain emanating from the elbowand knee joints that later escalated to severe levels on 18thSeptember 2015.

Background/Demographic Data

Theclient was a male patient with an age of 50 years. Demographic datahelps in arriving at a diagnosis since different genders havedifferent disease experiences hence, gender and age are important.

PatientHistory

Thepatient noticed symptoms of arthritis for the first time two monthsago whereby he started experiencing pain from his elbow joints thatprogressed over time leading to inflammation of his joints. Kneejoints were also painful at the time of encounter with the patientbut had only started showing symptoms of pain a week ago. Taking theinformation about the onset of arthritis was crucial since it helpsin classifying the disease based on the number of joints involvedwhich can be monoarthritis, oligoarthritis, and polyarthritis. Additionally, it helps in classifying the condition based on theperiod of onset that can be termed as acute occurring within a fewdays, sub-acute which is additive and occurs within a few weeks andchronic onset that takes months and years to manifest itself. Theprogression of the disease followed an additive pattern wherebyeffects began on the elbow joint and later inhabited the knee jointswhereby they became stiff and sore. Moreover, the patient gaveinformation about experiencing some mild warmth on the knee jointsbut claimed that the joints did not change in color. Stiffness wasmainly experienced in the morning for about 15 to 30 minutes that wasconfined mostly to the joint areas, and the condition would becomeworse when the joints were involved in the movement. Further, inquiryshowed that the patient had difficulty sleeping at night but hadneither fevers nor experiences of weight loss. The patient had nohistory of either peptic ulceration or cardiac diseases and nocontraindications with any drugs that were prescribed initially totreat other ailments that were not associated with arthritis.Finally, the patient was non-alcoholic, non-smoker, employed butlacked medical insurance cover (Pines et al. 2012).

FamilyHistory

Bothparents had suffered from the condition initially, but they weretreated successfully without disease recurrence after completing thedosage that was prescribed by the doctor. The patient’s father hadbeen affected at the elbow joint while the mother had arthritis ofthe wrist joint.

PhysicalExamination

Examinationof the joints, bones and muscles was conducted to assess deformitywhile the extremities were palpated for warmth using the hand dorsum. Palpation was also done for soft tissue structures, joint line, andbony tissue structures while the motion was initiated on joints tocheck for their tenderness. These processes showed loss of a rangeof motion, joint tenderness and presence of warmth on the joints thatwere affected with the patient experiencing severe pain during themotion. The forearms were flexed to ninety degrees, but no bulgingwas observed with only some swelling above the olecranon process. However, after a series of elbow movement, a flexion contracture wasobserved implying the presence of elbow synovitis. Palpating thesynovial cavity in the lateral recess showed signs of swelling andtenderness. On the other hand, the knee did not show any signs ofbulging and effusion after a comprehensive physical examinationthrough inspection of the joint and the alignment of the tibia andfibula (Sayler, 2005).

Assessment/Diagnosis

Laboratoryscreening of this condition helped in confirming the diagnosis,determining the disease stage and its prognosis. It involvedperforming laboratory tests such as Rheumatoid factor, Erythrocytessedimentation rate, and C-reactive protein. Additionally, imaging wasalso done on the elbow and knee joints to confirm the presence of thecondition and its progression. The results showed the presence ofarthritis in the elbow joint from the imaging result and laboratorytests conducted for rheumatoid factor turned positive.

Treatment/Recommendation

Themanagement of the patient will encompass both pharmacologic andnonpharmacologic therapies whereby the later will entail massage,diet, stress reduction through counseling and exercise. Treatment viamedication will involve the use of biological and nonbiologicalDMARDs (disease modifying antirheumatic drugs) which will be takentogether with other therapies.

References

Pines,J. M., Carpenter, C. R., Raja, A. S., &amp Schuur, J. D. (2012).Evidence-BasedEmergency Care: Diagnostic Testing and Clinical Decision Rules.Hoboken: Wiley.

Sayler,M. H. (2005). Theencyclopedia of the muscle and skeletal systems and disorders.New York, NY.

Williams,G. R. (2005). Shoulderand elbow arthroplasty.Philadelphia: Lippincott Williams &amp Wilkins.