The client I asses was an elderly female 70 years of age. She was admitted in an orthopedic ward. She was alone in the ward so the issue of privacy and safety was not a barrier. After initial greetings, I began examining her using different techniques including observation, interview, and examination.
In my observation, the patient looked exhausted. She did not appear to be in any pain and this was not reflected in her medical records. However, she appeared weak and somehow emaciated. I developed interested in knowing about her case. First, I looked at the patient history from the health records. I reviewed all the records for the patient for the last one year to see if there were frequent reported cases. From the health records, important information was obtained regarding the patient’s health status. One of the emerging frequent reported cases in the health records was mobility problem. After reviewing the health records, I then proceeded to a personal interview with the client. To assess the mobility, I asked the client to step out of the bed and got hold of a walking aid. I supported the client use the walking aid and we walked for about 15 steps. It was not that difficult to get information from the patient regarding her condition because she was in good mental condition. Overall, the presenting symptoms were obtained from the medical records and little from the patient. The client presented the following problems during the contact: the client complained of weak muscles resulting to dragging of feet when walking, shaking, difficulty lifting hips, and others. The client also presented spasticity.