Health assesment

Alison Wells is a 38-year-old woman with severe changes in mood. Her BP is 185/98. Her heart rate is 88bpm. Her Blood sugar level is 9.6 mmol/l. Cholesterol unknown. She is divorced and lives with
two young daughters, 5yrs and 8yrs. Weight is 81 kg. BMI 35. Weight at last appointment 86kg. No previous documented history of mood disorder. No other documented ongoing medical conditions.
Past medical history Cholecystectomy 2008
Gastro-Oesophogeal Reflux Disorder. Medications: Omeprazole

The assessment consists of 2 parts:
Part A: comprehensive clinical assessment, and
Part B: the case study report.

Note
Part A: Comprehensive Clinical Assessment
Using the Comprehensive Clinical Assessment Reporting Guideline (500 words max)

Part B: Case study report
The case study should address all following questions:
1a. WHAT IS GOING ON HERE? (750 words max)
• Patient’s presentation – what did the person present with? (one paragraph)

• Evident clinical manifestations – signs and symptoms. Please include both observed mental and physical health signs and symptoms.

1b. PATHOPHYSIOLOGY OF CLINICAL MANIFESTATION (750 words max)
• Pick one (1) aspect of the patient’s pathophysiological presentation. For example, the patient may have the following clinical manifestation:
• Low mood,
• Loss of appetite,
• Sleep disorder,
• Low energy

• How did the selected problem arise in pathophysiological terms?

2. WHAT ELSE DO I NEED TO KNOW? (1000 words max)
• What further information is required at this point?

• What other assessments/investigations need to be performed or recommended in order to complete the clinical picture?

• What aspects of the patient’s health history need further information to inform the comprehensive clinical assessment?
3. WHAT DOES THIS ALL MEAN? (500 words max)
• Overall clinical impression – based on above, students need to describe what they consider is going on with the patient?

• Provide details about the understanding of what is happening to the patient based on the clinical impression (consider and include both mental and physical considerations).

• How did the clinical assessment tool (explored in Assessment one) inform clinical judgment for this patient?