Individaul_Client_Health_History_and_Examination

Health History and Examination Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include relevant data for your client. Student Name :Grand Canyon | Date: June 9, 2012 | | | * Client/Patient Initials: SN | Sex :F | Age: 52 | Health History/Review of Systems(Complete and systematic review of systems) | Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications):Denies headache, Was involved in a motor vehicle accident in 2000 with minor head injury but resolved, and denies convulsion and no medication. | Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Denies headache, neck pain, no lumps /swelling nor any surgery and does not take any medication. | Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):20/20 vision denies neither blurred vision, no redness/swelling, tearing watering nor any medication. | Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, and medications): Denies earache, no discharge from the ears, has difficulty hearing and uses hearing aid in left ear she is not exposed to environmental noise and not any medication. | Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): No discharge, no nasal congestion, flaring, bleeding or injury, has dentures, has occasional seasonal allergies and take Benadryl as needed for allergies, visits dentist for routine dental care. | Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications): Small bruises, no moles, skin is dry and she uses Eucerin cream occasionally, denies itching, has recent hair loss and went to dermatologist was given prescription medication and shampoo but does not remember the name. Nails are brittle and normal. | Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications): No tenderness, lumps, pain from Axilla or discharge from nipples and does not carry out monthly breast self examination and has never had mammogram for the first time and not any medication. | Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications): Patient denies any leg pain, swelling, no skin changes, in both legs and ankle, gland not swollen and does not take any medication. | Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications): Presently but has chest pain once in a while when stressed out but denies shortness of breath, feet/ hands not swollen, Mrs. SU has 4 siblings brother 65 has Aortic valve repair in the past 1998, sister 45 with congenital heart disease, brother 50 with hypertension, father deceased at 75 from a heart attack. Patient does take Robbitussin occasionally for cough does not have any heart disease. She is constantly stressed out worried she will soon develop heart condition just like his family members. | Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications): Coughing, denies shortness of breath,pain both on inspiration nor expiration, no chest pain with breathing nor history of lung disease, smokes 1 pack of cigarette daily, lives in two bedroom condominium and works in the hospital, had last skin TB test July 2011, had last flu shot November 2011 with Pneumococcal vaccine, chest x-ray March 2011 and no medication. | Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications): Joint pain to both knees, stiffness and swelling slight redness in joints and takes Prescription Motrin/Cataflam 1 pills every 8 hours as needed. | Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications): Appetite good, no difficulty swallowing food, has occasional abdominal pain has bowel movement twice daily which is normal for him, history of gastro esophageal reflux disease (GERD) takes Zantac. | Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, suprapubic region or low back): Nocturia, polyuria, urine is yellow and has mild flank pain, has urinary tract infection in the past that was not treated. | Physical Examination (Comprehensive examination of each system. Record findings.) | Neurological System (exam of all 12 cranial nerves, motor and sensory assessments): 1. Olfactory nerve; The nares are patent.-Able to smell.Cranial Nerve II; Optic Nerve: Orange to pink in color .Size/Shape; Oval Cranial Nerve III, IV,VI; Oculomotor, Trochlea and Abducens: work together Lower edges of lids meet and upper eye lids covers adequately. Pupils constrict with light and remain constricted bilaterally with light. Eyes move easily and bilaterally in six cardinal fields of gaze and maintains gaze.Cranial Nerve V Trigeminal: Patient able to clench her teeth tightly. Temporal muscles feel strong and equal in size and strength. Tears when cornea is touched. Blinks her eyes.Cranial Nerve VII Facial Nerves: Symmetrical facial contours, lines, wrinkles and facial movement. Retains puffed cheek despite effort to collapse them. Able to differentiate salt, sugar and lime taste respectively. Cranial Nerve VIII Acoustic (Vestibulocochlea): Hears whisper and equal balance in both ears. Cranial Nerve IX and X Glosso pharyngeal, Vagus: Patient gags, voice is clear and strong. Cranial Nerve XI Accessory: Lifts shoulder and jaw firm. Cranial Nerve XII Hypoglossal: Tongue is still and centered on mouth floor. Fast, smooth tongue movement. - | Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland): No swelling, fracture or stiffness, no enlarged lymph nodes. | Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus): 20/20 vision, no visual loss, no pain, redness, tearing, nor double vision. | Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity): no hearing impairment, no ringing, tingling, earache in the left ear, and mild discharges noted in left ear. | Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat): Yellow nasal discharges, several missing tooth uses dentures, lips and tongue pale, no gum inflammation. | Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach self-examination techniques): No lesion, skin dry and intact, hair and nails clean, small bruises with dryness on lower extremities with discoloration of knees. Instructed to do report any unusual skin discoloration and do skin examination regularly. | Breasts and Axilla (deferred for purpose of class assignment) | Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps): no current problem. | Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S1 and S2, any extra heart sounds, murmur): pulse present strong and regular, grade 1 heart murmur heard on full .concentration | Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds): no enlarged lymph nodes, crackles heard on inspiration. | Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and range of motion): Swelling left knee with mild bruises, generalized weakness, pain on standing up. | Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness): Abdomen round and obsessed, skin is dark and dry, bowel sounds present in all four quadrants. | Genitourinary System (deferred for purpose of this class) | FHP Assessment | Cognitive-Perceptual Pattern: Able to comprehend, process information and knows that smoking is detrimental to health. Risk for cardiac diseases. Able to learn and comprehend new information and make own decision. | Nutritional-Metabolic Pattern: Eats whatever she wants and eats more during stressful periods, husband does the grocery and both does the cooking and enjoys that time together since the children does not live with them. Has good appetite, no food allergy. Typically eats 3 meals daily and eats biggest at night usually after 10 pm does not diet eats less fiber food and does not like drinking water, takes 2 cups of coffee daily and consumes 2 alcohols daily. | Sexuality-Reproductive Pattern: Happily married to the same man for 35 years and has good sexual relationship with husband. They have 3 children ages 33, 30 and 25 years. | Pattern of Elimination: Skin is dry, has 2 bowel movement daily and has occasional constipation and takes laxatives as needed. Urinates 2 to 3 times during the day without difficulty and wakes up to 5 times at night to urinate. | Pattern of Activity and Exercise: Able to perform her activities of daily living independently. Likes gardening and also takes 30 minutes walk in the neighborhood twice a week and desires to increase on that. | Pattern of Sleep and Rest: Difficulty falling at sleep at night, sleep only 4 hours at night does not take a nap. Does not take any sleeping pills. | Pattern of Self-Perception and Self-Concept: Happy with her accomplishment, and feels attained a fulfilled life. Income is adequate for her life style. | Summarize Your Findings(Use format that provides logical progression of assessment.) | Situation (reason for seeking care, patient statements): 52 year old female in good is in good condition, currently in middle adulthood and experiences some stress. Client is not sick currently was just used for the purpose of health examination. She stated she has a very good relationship with his family and is happily married for 35 years. | Background (health and family history, recent observations): Has a long term history of smoking and drinks alcohol. Mrs. SU father deceased at 75years from a heart attack, brother 65 has Aortic valve repair in 1998, sister 45 years with congenital heart disease, brother 50 with hypertension and diabetes, sister 40 with diabetes and diagnosed February 2012 with left breast cancer undergoing chemotherapy. Mrs. SU has nocturia, blood pressure taken 150/98 mm hg , left ear ache and discharges, recent knee pain ,stiffness and ache, constipation, poor dietary intact | Assessment (assessment of health state or problems, nursing diagnosis): Mrs. SU seem to have her life in order, smoking and lack of breast examination puts her at risk. Readiness for enhanced health learning. She is willing to improve on her physical activities. Risk for cardiac disease as evidenced with strong family history. | Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education): Mrs. SU health is not bad however adhering to some recommendation will improve her general health. I would recommend she does monthly breast self examination, and a yearly mammogram. Secondly, I would recommend her to programs that will help with quit smoking as smoking increase her chances of lung and cardiac diseases and will reduce her stress and anxiety levels. With the complaint of nocturia I would recommend seeing a physician and have her blood and urine tested to rule out diabetes and be followed up. Lastly I would recommend her to increase her fiber intake in her diet, and drink more water. The older a person gets the more important it is to keep up with your health status. Frequent examinations can uncover early signs of problems not readily detected by patient until the condition progresses to more advanced stage. Prevention is better than cure. References Jarvis, C.(2012). Physical examination & health assessment (6th ed). St Loius. MO: Saunders ISBN-13:9781437701517.The process of conducting a physical Assessment: A Nursing perspective, British Journal of Nursing (2006) Retrieved from GCU library at htt://library.gcc.edu:2048/login'url=http://search.ebscohost.com/login.aspx. | | * * * * * *