Question

I have an assignment and it is on making a nursing care plan and basically I am supposed to interview someone but i am having difficulty understand the pathophysiological question. I would like some examples of the questions/statements that I will be provided below.

What brought this patient to the hospital?

Admission diagnosis(es)

Explanation of pathophysiology for admission diagnosis(es) in your own words (include in-text citation after each explanation and include in reference list)

Past medical history (PMH)

Past surgical history (PSH)

Answer 1

What brought this patient to the hospital?
it means the principal reason for a person seeking medical attention. It is also known as chief complaint or present illness.
it is a statement typically in the patient's own words.
For example: I have chest pain.
Sticking with chest pain as an example you should ask:
Site: Where exactly is the pain?
Onset: When did it start, was it constant/intermittent, gradual/ sudden?
Character: What is the pain like e.g. sharp, burning, tight?
Radiation: Does it radiate/move anywhere?
Associations: Is there anything else associated with the pain, e.g. sweating, vomiting.
Time course: Does it follow any time pattern, how long did it last?
Exacerbating / relieving factors: Does anything make it better or worse?
Severity: How severe is the pain, consider using the 1-10 scale

Admission diagnosis:
The diagnosis provided by the physician at the time of admission which describes the patient's condition upon admission to the hospital.
Chief complaint of often guides Diagnostic decision making.
For example if the definitive diagnosis of acute MI is not render prior to admission then the symptom chest pain (angina pectoris) is the admitting diagnosis.

Explanation of pathophysiology for admission diagnosis:

Angina pectoris: episodic severe constricting pain in the chest radiating from pericardium due to ischaemia of cardiac muscles. In this condition pain is produced due to hypoxia of myocardial tissue.

Venkatesh D., Sudhakar H.H., 2010,"Basics of medical physiology for nursing students", Wolters kluwer.

Therefore we need to admit this patient for proper oxygenation & further investigation.

Past Medical History (PMH): It is a record of past Medical illness that are or may be relevant to a patient's current state of health.

Important for determining the risk factors, diagnosis and treating a disorder.

For eg: allergies, immunization, any chronic illness

Past Surgical History: gather information about any kind of past Surgical intervention.

For eg: cardiac catherisation