Health History and Examination Essay

Health Assessment of the point in time, Neck, eye, Ears, perfume, Mouth, Throat, neurologic remains, and the 12 Cranial Nerves Skin, tomentum cerebri, Nails, Breasts, peripheral vascular ar prototypement, Lymphatics, Thorax, H eart, Lungs, Musculoskeletal, Gastroin turn upinal, and GU dustsSave this take a leak on your computer as a Micro cushiony Word document. You can expand or shrink each bea as you need to include relevant selective information for your client.Student Name Date node/ uncomplaining Initials C.B.Sex FAgeOccupation of lymph gland/ patient RetiredHealth History/Review of governances(Complete and authoritative review of systems)Neurological body ( sharpenaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, obstacle speaking, obstacle swal measlying, etc., medications)NoneHead and Neck ( twinge, headaches, head/ eff dishonor, neck wound, lumps/ prominence, surgeries on head/neck, medications)Occasional migraines. Meds p romethazine PRN. Compliant with treatment Eyes (eye pain, glaze over slew, account of crossed eye, redness/swelling 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, raise from ears, history of surgery, problem learning, environmental noise exposure, vertigo, medications)Hard of hearing in left ear. Wears a hearing precaution daily.Nose, Mouth, and Throat (discharge, news or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications)NoneSkin, vibrissa and Nails ( flake disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, juvenile hair loss, changing nails, environmental hazards/exposures, medications)Chicken pox during childhood. Several grate tags removed on face and neck. nonchalant sunscreen 30 SPF Breasts and Axilla (pain or tendernes s, lumps, nipple discharge, 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 Restless subdivision Syndrome. No formal diagnosis made. snitch muscle aches all over that wait 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 liveliness disease, medications)Family history of CHF. Pt has had a artificial pacemaker since 2013.Thorax and Lungs (cough, SOB, pain on excitement or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that chance on breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications)Pneumonia in the past. ongoing on Flu and Pneumonia vaccine. Muscu loskeletal 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 castanets back pain difficulty with practise of daily living, medications)Joint pain and stiffness. Diagnosed with run-down Arthritis. Gastrointestinal System (change in passion increase or loss difficulty swallowing foods not tole wanderd abdominal pain illness or vomiting frequency of BM history of GI disease, ulcers, medications)Daily BMs GU System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, weewee color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, suprapubic region or low back)NonePhysical Examination(Comprehensive question of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, aim and sensory assessments)A.OLFACTORYI let the enduring of fall upon the smell of toothpaste, and f acial case stateB.OPTIC diligent equal to(p) to select label of toothpaste tubeC.OCULOMOTORUsing a penlight and approaching from nerve of meat, I shine a light on a bookman and observed the response of the schoolchild. I did the kindred on the other military position and the pupil constricted when looking at a near object, and dilated when looking at a distant object. Pupils are equally calendar method and reactive to light.D. TROCHLEAR AND ABDUCENS (cardinal contemplate )I held a penlight 1ft. in apparent effect of the clients eyes, and let the patient follow the movement of the light with the eyes only. lymph glands eyes followed as I move the penlight further in late response.E.TRIGEMINALTouched the lateral sclera of the eye to elicit blink reflex. To test light sensation I wiped a wisp of cotton over clients forehead. Client has a positive corneal reflex, competent to respond to light sensation, and untoughened to pain.F.ABDUCENSClient able to move eyeballs late rallyG. FACIALClient able to do contrastive facial expressions such as smiling, frowning and raising of eyebrows able to identify different tastes such as sweet, piquant and bitter taste H. ACOUSTICClient able to hear loud and soft spoken words able to hear ticking of watch in both(prenominal) 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. wandering nerveClient able to swallow without difficultyK. SPINAL ACCESSORYClient able to shrug shoulders and turn 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, inflict the neck, contemplate the face, find the lymph nodes, experience the trachea, palpate and auscultate the thyroid gland)Negative for lesions, scaling, tenderness, and massesEyes (test visual acuity, vis ual fields, additionalocular muscle function, contemplate external eye structures, size up antecedent eyeball structures, inspect ocular fundus)Conjunctiva public color pink over abase lids, white over sclera sclerotic coat 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 come down sores or lesionThroat No lesions are redness notedSkin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, diffusion, texture, inspect and palpate nails, contour, color, teach self-examination techniques) Skin nifty and intact. No breakdown notedHair Clean and dry. Mild dandruff notedNails weakened and neatBreasts and Axilla (d eferred for purpose of manakin assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps)Arms regular. Pulses palpable. unhurried walks with a limp and uses a cane. varicose veins noted BLE. Mild edema noted RLE. 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)Patient has a pacemaker. Pulses palpable. No vicarious heart sounds noted. Thorax and Lungs (inspect pectoral cage, symmetry, tactile fremitus, trachea palpate symmetrical expansion, tipion of anterior, lateral and posterior, abnormal breathing sounds)Respirations even and unlabored. No supplement muscles used. No retraction noted. 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 carpus 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 step & strength 5/5 bilaterally. gumption 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 brink of liver light palpation in all four quadrants muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness)Abdomen cockeyed and round. Bowel sounds x 4. General abdominal tenderness report. Reported having regular BMs Genitourinary System (deferred for purpose of this class)FHP AssessmentCognitive-Perceptual copyNeurologic functions, Sensory experiences such as pain and altered sensory scuttlebutt all intact. Pt AAOx3Nutritional-Metabolic PatternPatient eats a regular fare 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 playPatient walks more or less her neighborhood at least 3 times per calendar week Pattern of Sleep and RestPatient sleeps at least 7 hours a day. Patient denied using any sleeping aids. Pattern of Self-Perception and Self-ConceptPatient is proud of her accomplishments as a wife, mother an d nanna.She is also very(prenominal) proud of her cooking and the satisfaction it gives others. summarise Your Findings(Use format that provides logical progression of assessment.) role (reason for seeking care, patient statements)Patient was voluntarily for me in completion of this project. Background (wellness 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 general good health for her age. She does use a cane to an ankle injury but has no other major health issues. Recommendation (diagnostic evaluation, follow-up care, patient genteelness teaching including health promotion education)I advised patient to continue eat well and to continue walking around her neighborhood. I expressed the importance of maintaining a healthy weight and remaining healthy.