Physical Examination & Health Assessment in a Rheumatoid Arthritis Patient

Physical Examination & Health Assessment in a Rheumatoid Arthritis Patient

Physical examination and health assessment are major components when you first meet your patient every time he or she admitted. They are important in the aid of collecting patient’s data, designing care plans, giving treatments, and evaluating the outcomes.

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Physical examination is a process during which you use your senses to collect objective data. Know normal findings before you begin to distinguish the abnormal ones. Effective communication skills are essential in establishing the trust needed to proceed with the examination. Physical examination provides another perspective; whereas the health history allows you to see your patient subjectively through eyes, the physical examination now allows you to see your patient objectively through senses. The objective data complete the patient’s health picture.

Health assessment is an important component in clinical settings. Health assessment is to collect data relevant to the patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to pinpoint actual problems, and to spot factors that place the patient at risk for health problems.

Following is a case study of a patient with rheumatoid arthritis, who was admitted because of swelling and burning pain. We will look into how health assessment is important to her and what is the difference in the outcome of care to the patient.
A. Background

Rheumatoid arthritis is an autoimmune disease where the body’s immune system attacks normal joint tissues, causing inflammation of the joint lining. This inflammation of the joint lining, synovium causes pain, stiffness, swelling, warmth, and redness of the affected area. The affected joint may also lose its shape, resulting in loss of range of motion. Rheumatoid arthritis is an ongoing disease, with active periods of pain and inflammation, which is called flares or flare-ups, alternating with periods of remission, when pain and inflammation disappear. Rheumatoid arthritis can affect many different joints. It can even affect parts of the body other than the joints, including the eyes, blood, the lungs, and the heart in some people (Pfizer, 2010).
B. History
B1. Biographical Data

Ms. Li Ho Lam was born in 3rd December 1959; she is now 52 years old. Ms. Li’s education level is up to Form three in secondary school. She quitted her job as a salesperson 5 years ago, and she is now a housewife. Ms. Li is married and has two daughters which are 20 and 17 years old. The four of them live together in an apartment in Shek Kip Mei. Her cell phone number is 99871256 and her husband’s cell number is 91235520.
B2. Reason for Seeking Care

Ms. Li complained that both of her hands are swelling and have burning pain for one day. Her pain scale is 8, and she did not take any medication.
B3. Health History

For health history, Ms. Li is allergic to seafood. After taking any kinds of seafood, rashes will appear on Ms. Li’s body and they will be itchy. Ms. Li was diagnosed with rheumatoid arthritis in year 2010. She is taking aspirin to relief her flare-ups, but she has stopped for a few days. She does not have any other health probl