Week 5 Assessment Person
Mrs. Romer, a 58 year old female came to the clinic today with her neighbor Mrs. Donge. She asked for help crying I cannot stand this pain anymore. As her neighbor and her best friend, Mrs. Donge said that several years ago the woman was very strong and always felt great. Now, this woman is retired and does not feel well. She had not had any problems until she was involved in a serious car accident. Fortunately, Mrs. Romer survived. That rainy night, she and her husband were going to their relatives, who lived in another town. They wanted to take their only child Chris home after a holiday at Mrs. Romers sister. Several months later after that horrible night, the woman recalled that she was not even able to move her head, and the lower part of her body seemed motionless. Nevertheless, the doctors reassured that she was not paralyzed.
Her son, Chris, now a 19 year old boy, is the only one who takes care of his mother. He always brings medicine and helps her with het everyday chores. Sometimes, when Mrs. Romer gets really strong lower back pain, she begins to cry saying God, you should have better taken me away to my dear Michael!
Mr. Romer died immediately. Woman has been living alone in a big house, and her best friend Mrs. Donge, who lives in the same street, always supports her neighbor. Nowadays, Chris is studies in college and, therefore, cannot provide her with permanent assistance. However, he visits his mother every weekend and drives her to local clinic for examination.
Mrs. Romer has a serious problem with her lower abdomen after that car accident. Her left kidney was totally damaged, while the right one was only injured. She has gone through difficult transplant operation. In addition, the woman reports that I could not move my neck normally for several months after car accident. Woman states that the pain in neck remains dull and appears from time to time when she slightly nods or tilts her head.
When Chris comes home, he often sees his weak mother sitting in the yard and whispering something. He said that ...mother seems to have definitely changed since that time. Besides her poor physical health, she looks pale and upset. It was not only a trauma of her physical body but also of her psychological state of mind.
Mrs. Donge and her husband, 60-year-old man, try to visit their neighbor twice a week together. Mr. Donge can relief womans pain about her husband, because they were good friends and always helped each other with cars. They also liked to go hunting together times ago. Accordingly, this married couple brings Mr. Romer back to life. Fresh juice, vegetables, and fruits are the regular food we bring her, says the man. Mrs. Romer also takes special vitamins and pills regularly.
Mrs. Romer has always been happy and easy-going person without any signs of sadness or depression. She reports that now she is more reserved and usually indifferent about many issues. She has lost her appetite and weight. About six years ago, she was plump enough but now she is quite slim for a 58-year-old woman.
The woman denies history of bad habits. She has never smoked and was never addicted to other things. Mr. Romer used to go in for sports years ago on a regular basis. She states that she generally likes to walk a little around the district in the morning and before going to bed. Mrs. Romer states that she has recently quit doing this because of constant annoying giddiness. Woman says that she feels scared to faint.
Yesterday evening, when Chris came home for a weekend, he noticed that his mother refused to eat and had unusual complexion. She states that ...I (she) just drank a little water and went out the house to read a book. Son tried to make her eat and then take pills but woman refused to do that. Chris felt anxious about his mother and almost two hours later saw her unconscious lying on the grass in the yard. The woman was immediately taken to the hospital for examination and testing.
Mrs. Romer is asking for medication and guidance that will improve her health state and make her feel better. She appears to be reliable in her own statements, and her neighbors as well as her son have confirmed this information.
General appearance: Clean, appropriately dressed, underweight, and pale complexion. Physical body looks weak and facial expression is upset.
Vital signs: Serum calcium is higher than the norm at the level of 13.9. According to complete blood count (CBC), hematocrit is 33% and hemoglobin is 11.1 g/dl. These rates are below the norm of a healthy person. Renal transplant is connected with evident anemia. There is a strong influence of kidney work on the rate of hemoglobin and hematocrit and vice versa (Stratta, 2008).
Pain: Deep somatic pain in lower back and dull pain in neck. Difficulty in leaning, walking, getting up, and sitting down. There is balance disturbance and signs of pain increase. Chronic pain in lower back did not stop after the injury. It still persists and also outlasts the purpose its protectiveness. The intensity of pain corresponds to physical findings.
Individuals self-report is the main indicator about this issue. The end-stage renal disease (ESRD) has started to develop progressively. Serum calcium is higher than the norm and indicates kidney dysfunction because kidney is responsible for creating serum calcium (Jarvis, 2012).
Neck pain causes tingling in shoulders and radiates on this part of body. Restrictiveness of motions such as turning neck and lifting some objects of normal weight for an average woman of 58 years old is examined. The patient cannot touch the chin to the chest, turn the head to the right and left and reach each shoulder with each ear or lean the head backward. Individuals neck is not supple (Jarvis, 2012).
Cardio: She denies any serious discomfort in chest area. Sometimes, mild heartache and shortness of breath can occur when she remembers a horrible car accident and her dead husband, but there are no murmurs heard on osculation. Pulse in the neck, wrists, groin, and feet is above the norm and blood pressure is below the norm. Irregularity of heartbeat is observed.
Pulmonary: No problems with lungs. They are clear in all areas. There are no issues revealed by percussion.
Abdomen: Is distended, bowels are not sound. General tenderness of the abdomen is caused by the car accident and also enhanced by lower back pain. Chronic nonmalignant pain is associated with musculoskeletal conditions such as kidney dysfunction (Jarvis, 2012).
Medications: Vitamins C, B12, and iron pills twice a day. Start dose amounts to half of the recommended dose with gradual increasing to the full dose (NKUDIC, 2006). She does not take them in divided doses and with food and often skips intakes.
Affect/Mood: This patient is unhappy and weak. The energy level is quite low. The patient does not smile and is reserved. When talking about her present life and activities, she becomes nervous because she feels bored most of the time. She avoids eye contact very often. She always avoids conversations with people and seems to be nice only with her neighbors and son. Woman becomes very emotional when talking about her husband.
Review of medical records: Every month she undergoes physical checkup of her kidney transplant and some blood tests. During last six years, the rate of hemoglobin and hematocrit have changed. Inflammation of the transplant apparently influences these indicators (Stratta, 2008). Anemia has been noticed since renal transplantation took place.