Patient Visit Summary Report

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Confidentiality Disclaimer - This essay uses patient initials only. No identifying features are included within this essay. Patient: BA Patient’s age: 63 years old 1. Medical conditions (active) : After taking the patient’s medical history, I found out that the patient experiences several active medical conditions. She was diagnosed having rheumatoid arthritis, diabetes type II, sleep problem, high blood pressure and high cholesterol. She got rheumatoid arthritis when she was 49 years old, and has been having this for 14 years. She will feel the pain at places involving joints like the hands, knees and hips. She also feels the pain in the area around her head and neck, which contributes to headache. This is actually a condition where our immune system which is supposed to fight infection, attacks the cells lining our joints, causing them to be swollen, stiff and painful, and in process, damaging the joint, the cartilage and our nearby bone1. The sharp pain she feels usually radiates from her heels to her hands. Walking is really painful for her due to the inflammation of the joints. This condition is worsened during hot weather and if she feels stress, where it triggers pain most. Not only that, she feels exhausted and tired easily after doing any activities and thus, she tends to sleep a lot due to this illness. The patient also has a condition called fibromyalgia, which is a disorder that causes muscle pain and an extreme feeling of tiredness (fatigue)2. Patients will experience chronic fatigue syndrome and achy muscles, and this is treated with anti-inflammatory medications. Fibromyalgia affects her lifting ability, which limits movement and activities such as shopping. According to the patient, this bothers her ... ... middle of paper ... 9. National Heart, Lung and Blood Institute. What is COPD? [Internet]. United States : U.S. Department of Health & Human Services; 2013 [updated July 31]. Available from : 10. World Health Organization Europe. The Solid Facts (Second Edition). Denmark : World Health Organization; 2003. 11. Cleveland Clinic. Occupational and physical therapy for arthritis [Internet]. Ohio : Cleveland Clinic; 2012 [updated September 17]. Available from : 12. MedlinePlus. Type 2 diabetes – self care [Internet]. United States : National Institutes of Health; 2013 [updated October 31]. Available from :
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