Health History and Examination Essay

Health judgement of the Head, Neck, Eyes, Ears, Nose, Mouth, pharynx, Neurological remains, and the 12 Cranial Nerves Skin, tomentum, Nails, Breasts, encircling(prenominal) Vascular system of rules, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and genitourinary organisationsSave this form on your computer as a Microsoft Word document. You can expand or shrink distri onlyively area as you need to include relevant data for your invitee.bookman Name Dateguest/ make believeed role Initials C.B.Sex FAgeOccupation of Client/ longanimous RetiredHealth History/Review of dodges(Complete and systematic review of systems)Neurological System ( full pointaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, clog speaking, difficulty sw anyowing, etc., medications)noneHead and Neck ( ache, headaches, head/neck dishonor, neck pain, lumps/ protrusion, surgeries on head/neck, medications)Occasional migraines. Meds Phenergan PRN. tea ch competent with treatment Eyes (eye pain, blurred vision, biography of crossed eye, redness/ projection in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications)NoneEars (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications)Hard of hearing in left hand ear. Wears a hearing aid workaday.Nose, Mouth, and Throat (discharge, insanes or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications)NoneSkin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent pilus loss, changing nails, environmental hazards/exposures, medications)Chicken pox during childhood. Several skin tags aloof on face and neck. Daily sunscreen 30 SPF Breasts and Axilla (pain or tenderness, lumps, nipple dis charge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications)Noneperipheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications)Pt. states she has lodgeless Leg Syndrome. No formal diagnosis made. Frequent energy aches all over that pick up routine cortisone injections. 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)Family history of CHF. Pt has had a pacemaker since 2013.Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with ventilation, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications)Pneumonia in the past. Current on Flu and Pneumonia vaccine. Musculoskeletal System (joint pain rigorousness swelling, heat, redness in joints limitation of impelment muscle pain or cramping deformity of bone or joint accidents or trauma to bone back pain difficulty with activity of daily living, medications)Joint pain and stiffness. Diagnosed with Rheumatoid Arthritis. Gastrointestinal System (change in appetite increase or loss difficulty set downing foods not tole aimd abdominal pain nausea or vomiting frequency of BM history of GI disease, ulcers, medications)Daily BMsGenitourinary 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)None personal Examination(Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments)A.OLFACTORYI let the longanimous identify the smell of toothpaste, and facial grimace notedB.OPTIC enduring a dapted to read label of toothpaste tubeC.OCULOMOTORUsing a penlight and approaching from spatial relation, I shine a light on a savant and spy the response of the pupil. I did the same on the other side and the pupil constricted when looking at a near object, and dilated when looking at a distant object. Pupils are equally round and reactive to light.D. trochlear nerve AND ABDUCENS (cardinal gaze )I held a penlight 1ft. in front of the clients eyes, and let the patient follow the livement of the light with the eyes only. Clients eyes followed as I move the penlight but in late response.E.TRIGEMINALTouched the lateral sclera of the eye to rouse blink reflex. To test light sensation I wiped a wisp of cotton over clients forehead. Client has a positive corneal reflex, sufficient to respond to light sensation, and sensitive to pain.F.ABDUCENSClient sufficient to move eyes laterallyG. FACIALClient able to do various facial expressions such as smiling, frowning and raising of ey ebrows able to identify different tastes such as sweet, salty and bitter taste H. ACOUSTICClient able to hear loud and soft spoken words able to hear ticking of watch in both ears. I.GLOSSOPHARYNGEALClient able to identify different tastes such as sweet and salty, able to move tongue from side to side and up and down, able to swallow without difficulty with positive gag reflex J. VAGUSClient able to swallow without difficultyK. SPINAL ACCESSORYClient able to shrug shoulders and flexure head from side to side against resistanceL. HYPOGLOSSALClient able to protrude tongue at midline and move from side to side Head and Neck ( experience the skull, scrutinise the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland) ostracize for lesions, scaling, tenderness, and massesEyes (test ocular acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fund us)Conjunctiva normal color pink over pull down lids, white over sclera Sclera whiteEars (inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity)Negative for redness, swelling, discharge, or foreign bodies Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat) Nose Negative for lesions, swelling. Some nasal discharge noted Mouth Negative for canker sore sores or lesionThroat No lesions are redness notedSkin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach introspection techniques) Skin moderately and intact. No breakdown notedHair Clean and dry. nutty dandruff notedNails Trimmed and neatBreasts and Axilla (deferred for purpose of fork assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses inspect legs, venous pattern, v aricosities, pulses, color, swelling, lumps) coat of arms symmetrical. Pulses palpable. Patient walks with a limp and uses a cane. Varicose veins noted BLE. Mild edema noted RLE. Cardiovascular System (inspect and palpate carotid arteries, jugular vein venous system, precordium heave or lift, apical impulse auscultate rate and rhythm identify S1 and S2, any extra heart sounds, murmur)Patient has a pacemaker. Pulses palpable. No abnormal heart sounds noted. Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea palpate symmetrical expansion, percussion of anterior, lateral and posterior, abnormal breathing sounds)Respirations even and unlabored. No accessory muscles used. No retraction noted. Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, drift of doubt inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of move 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)Muscles developed without atrophy/hypertrophy. Arms & legs symmetric. Novaricosities, or tenderness. Joints non-tender, without swelling, and with full ROM. Muscle tone & strength 5/5 bilaterally. Spine has full ROM and is without tenderness or deformities. 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 palisade of liver light palpation in all four quadrants muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tende rness)Abdomen firm and round. Bowel sounds x 4. General abdominal tenderness reported. Reported having regular BMs Genitourinary System (deferred for purpose of this class)FHP AssessmentCognitive-Perceptual linguistic ruleNeurologic functions, Sensory experiences such as pain and altered sensory input all intact. Pt AAOx3Nutritional-Metabolic PatternPatient eats a regular diet and watches what she eats.Sexuality-Reproductive PatternPatient has had 8 children and 1 miscarriage.Pattern of EliminationPatient reported having daily BMsPattern of Activity and ExercisePatient walks just about her neighborhood at least 3 times per week Pattern of Sleep and RestPatient sleeps at least 7 hours a day. Patient denied exploitation any sleeping aids. Pattern of Self-Perception and Self-ConceptPatient is proud of her accomplishments as a wife, mother and grandmother.She is also very proud of her cooking and the satisfaction it gives others. add up Your Findings(Use format that provides logical progression of assessment.) Situation (reason for seeking care, patient statements)Patient was voluntarily for me in completion of this project. Background (health and family history, recent observations)Patient is a mother of 8, grandmother to 22 and great grandmother to 7 Assessment (assessment of health state or problems, nursing diagnosis)Patient is in overall good health for her age. She does use a cane to an ankle injury but has no other major health issues. Recommendation (diagnostic evaluation, go through care, patient education teaching including health promotion education)I conscious patient to continue eating well and to continue walking around her neighborhood. I expressed the importance of maintaining a healthy weight and stay healthy.