Patient’s Medical History and Nursing Care Plan Essay

Patient Name: Mary

Chief Complaint: The client complained about having a rash on her face.

History of Present Illness: The patient said that the rash appeared on her skin after the holiday she spent hiking and doing various outdoor activities in the Appalachians.Patient’s Medical History and Nursing Care Plan Essay

Past Medical History

Family History: Mary’s mother had a diagnosis of rheumatoid arthritis. Nevertheless, the client’s father does not have any health issues.

Personal and Social History

Mary is thirty-five years old. She occupies the position of an electrical engineer. At the age of nine, the client underwent the tonsillectomy procedure due to multiple issues and infections that bothered her throat. However, Mary did not have any illnesses or health problems after the case described above as she maintained a healthy lifestyle. It would be proper to mention that the client has never given birth to a child and has not been hospitalized in her entire life due to the absence of complaints. The patient does not consume tobacco products and drugs. However, she prefers to drink a glass of wine every night at dinner. The client has got a master’s degree in engineering. It would be proper to mention that Mary has been living with her boyfriend within the past five years. Patient’s Medical History and Nursing Care Plan Essay

General: Mary lost weight. Also, she has a high fever and fatigue.

Skin: The medical examination showed that the patient’s face was covered with a rash.

Head and Neck: The client has no health problems with her head and neck.

Eyes, Ears, Nose, Throat, and Mouth: Mary said that she felt mouth soreness.

Lymphatic System: The client has no health problems in her lymphatic system.

Chest and Lungs: The client has no health problems in her chest and lungs.

Heart and Blood Vessels: The results of the blood pressure measurement procedure are the following: BP one hundred and twelve/sixty-six mm Hg; HR sixty-two BPM and regular. Patient’s Medical History and Nursing Care Plan Essay

Genitourinary System: The client has no health problems in her genitourinary system.

Musculoskeletal System: Mary said that she felt some pain and ache in her muscles. Perhaps, this is a consequence of intensive outdoor activities. When a person is not used to an active lifestyle, his or her muscles are likely to be sore after a set of physical exercises (Pinto, Berenguer, & Martins, 2015). The most painful zones were the patient’s hands and wrists.

Nervous System: The client has no health problems with her nervous system. Patient’s Medical History and Nursing Care Plan Essay

Physical Examination

General: As it is mentioned above, the examination showed that Mary lost her weight and had an increased fever and fatigue.

Mental Status: Also, the woman does not have any psychological issues. Therefore, she can be claimed mentally healthy.

Skin: A plethora of red boils emerged on Mary’s facial skin. However, the rest of the body does not seem to have the same issue. It would be proper to mention that the densest concentration of the rash can be observed on the client’s cheeks and nose.