Physical Examination & Health Assessment in a Rheumatoid Arthritis Patient

Introduction

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.

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 problems besides this.

Ms. Li had chicken pox in year 1965, and had recovered in two weeks. For hospitalization and operation, Ms. Li has had two times of caesarean section with general anaesthesia done in QueenElizabethHospital in year 1991 and 1994.

B4. Family History

Ms. Li’s mother had a history of rheumatoid arthritis; and her father had a history of hypertension and high cholesterol.

B5. Physical Examination

Ms. Li is 155 cm tall and weighs 59 kg. Ms. Li’s vital signs are taken. Her blood pressure is 140/86 mmHg; pulse rate is 66/min; respiration rate is 16/min; and temperature is 37.2?

B6. Interview

Since Ms. Li was diagnosed with rheumatoid arthritis, she has flare-ups every six to eight months. Acute episodes involve hand joints are treated with aspirin which gives relief. She experiences morning stiffness, which lasts half an hour to one hour. Her joints feel warm, swollen and tender. She had lost 5 kg over last three years and feels fatigued much of the time. Ms. Li could not sleep well and did not rest more. She was encouraged to do daily exercises, but she did not do them regularly due to her fatigue. She took aspirin for acute flare-ups, but when she feels better in a few days, she decreased dose by herself.

C. Health Assessment and Result

C1. Inspection

Inspection has to be done because swelling, masses, and deformity at joints greatly affect range of motion and activities of daily living.

First, Jarvis (2004) stated that note the size and contour of Ms. Li’s joint. Inspect her skin and tissues over the joints for color, swelling, and any masses or deformity. Presence of swelling is significant and signals joint irritation.

Ms. Li’s hands are swelling; it may be due to excess joint fluid, thickening of the synovial lining, inflammation of surrounding soft tissues, such as bursae and tendons, or bony enlargement. Deformities include dislocation, subluxation, contracture, or ankylosis, but it does not present in Ms. Li’s case. She might have to take Aspirin as prescribed to relief pain and to reduce inflammation (Poulis, Kretsi, Apostolopoulo, Zeeris & Vagenas, 2003).

C2. Palpation

Palpation is an important examination tool as it can help to find out many abnormalities, such as fluid accumulated in joints and tenderness. Patients might feel pain, flare-ups, and hard to move the joints.

Tijhuis, Zwinderman, Hazes, Breedveld, & Vlieland (2003) stated that, to start palpation, palpate each joint of Ms. Li’s hands, including its skin for temperature, its muscles, bony articulations, and area of joint capsule. Notice any heat, tenderness, swelling, or masses on Ms. Li’s hands. Joints normally are not tender to palpation. If any tenderness does occur, try to localize it to specific anatomic structures, such as skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule. The synovial membrane normally is not palpable. When thickened, it feels “doughy” or “boggy”. A small amount of fluid is present in the normal joint, but it is not palpable. Palpable fluid is abnormal, as fluid is contained in an enclosed sac. If you push on one side of the sac, the fluid will shift and cause a visible bulging on another side.

Ms. Li’s hands are tender, but no masses found in her joints. However, fluid is palpated as “boggy”. This can also be shown by her swelling hands. She might have to take Aspirin as prescribed to relief pain and to reduce inflammation as mentioned above (Karlsson, Berglin, Wa & Jonsson, 2006).

C3. Range of Motion

Assessing the range of motion is important too because it extremely affects the activities of daily living when the range of motion is decreased, and limitations occur. Patients might have to refer to physiotherapist to learn some exercises in order to improve the range of motion and back to normal again.

Codd, Stapleton, Veale, FitzGerald & Bresnihan (2010) stated that when assessing for the range of motion, ask Ms. Li for active range of motion while stabilizing the body area proximal to that being moved. Familiarize with the type of each joint and its normal range of motion in order to recognize limitations. If there is a limitation, gently attempt passive motion. Anchor the joint with one hand while the other hand slowly moves it to its limit. The normal ranges of active and passive motion should be the same. If any limitation or any increase in range of motion occurs, use a goniometer to measure the angles precisely. Joint motion normally causes no tenderness, pain or crepitation.

Ms. Li’s range of motion of her wrists and fingers appear limitations, but they can be moved in passive motion slowly. It might be affected by her swelling hands and the accumulation fluid in the joints. She might have to consult physiotherapist for exercising since she did not exercise regularly and has a decreased in range of motion (Palmer, Gaafary & Miedany, 2007).

C4. Pain Assessment

Patients’ self-report is considered the most accurate way to detect and measure pain.

Pain can be categorized by duration, site of pain (location), cause (etiology), or qualities (severity). Use the mnemonic COLDSPA to recall and assess the current symptoms of Ms. Li by asking the following questions: 1. Character: What does it feel like2. Onset: When did the pain begin3. Location: Where does it hurtCan you point to where it hurts4. Duration: How long does it last5. Severity: Rate severity by using appropriate pain scale. 6. Pattern: Does anything make it better or worse7. Associated Factors: What other symptoms occur with it?

Ms. Li answered by saying the pain on her hands feels like burning; it began yesterday when she woke up in the morning; it hurts both of her hands, especially fingers and wrists; the pain lasts forever and does not go away; pain scale is 8; resting is better, but it became worse when she moves her hands; there is no other symptoms with it.

After understanding the situation of Ms. Li, medication prescribed can be given to her, such as Aspirin which can help to relieve pain and reduce inflammation.

Conclusion

Physical examination and health assessment are very important in understanding patients’ health condition as shown in the example above. However, it only showed a few of them, there are much more ways of physical examination and health assessment to look at.

Reference

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http://www.arthritis.com/rheumatoid_arthritis_symptoms.aspx

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