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
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Student Name: Moronke Akindele Date: 25 September 2018
Client/Patient Initials: MN Sex: Male Age: 70
Occupation of Client/Patient: Business man
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):
No report of any neurological disorder in the patient.
Patient reports minor headaches few times in a month (Thinks it is related to hypertension).
No history of head injuries, convulsions, or difficulty in swallowing.
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications):
No report of the patient having pain in the neck or head.
No lumps or pain on neck.
No history of any surgery on the head or on the neck.
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):
The patient reports having no history of vision problems or any eye surgery.
Eye allergy due to dust.
Patient undertakes regular eye check-up once a year with the last one on August 5th 2017.
Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications):
No report of any discharge from the ears.
No pain on the ears.
The patient reports a surgery 20 years ago to remove a foreign object on the left ear.
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications):
No history of any mouth sores or lesions.
No history of nosebleeds or bleeding gums.
No history of sore throat.
The patient reports to regularly clean his teeth with dental visits once a year with the last one on 5th August the same day he was doing his eye check-up.
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):
No report of any skin disease.
Normal skin color.
No allergies to environmental exposure.
The patient denies taking any skin medications.
The patient also claims to practice regular hygiene, which involves cleaning his skin, hair, and nails.
Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications):
The patient reports a lump on his left breast, which after investigation revealed no health issue.
Mammography done on 4th March 2016 revealed normal health.
The patient has been regularly performing self-breast exams to detect any growth of another breast lump.
Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications):
The patient reports having Arthritis, which causes a lot of pain on his legs and joints.
Swelling of the legs and ankles.
The patient reports taking medications to address the pain experienced due to the Arthritis.
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):
No chest pain reported.
The patient reports having hypertension.
Family history of heart disease with his father having died from hypertension and diabetes complications.
The patient reports taking hypertension medications.
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):
No report of the patient having cough or pain while breathing.
No evidence of lung disease.
The patient reports to have a history of being a smoker for 10 years, which he eventually quit when he was 50 years old.
No medications taken in relation to chest and the breathing system.
Yearly flu shot.
No report of pneumococcal vaccine.
No report of ever taking a chest x-ray.
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):
Leg and joint pain, which is attributed to Arthritis.
Pain is severe when engaging in vigorous activities.
Regular exercises to strengthen the bones and joints as directed by the physician.
No report of any serious accident, which might have affected the bones.
Patient is able to perform normal activities without help but at a very slow speed.
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):
Patient repots regular and normal bowel movements.
The patient has an increased appetite with a preference to soft foods.
No difficulty in swallowing.
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):
The patient has an increased urination frequency.
Urine is clear which is attributed to the high amount of water that the patient takes every day.
No history of urinary tract infections or yeast infections.
(Comprehensive examination of each system. Record findings.)
Neurological System (exam of all 12 cranial nerves, motor and sensory assessments):
Patient has slowed movement due to Arthritis, which has affected the joints and the muscles.
Legs are numb at times, which makes the patient unable to detect touches or other sensations.
The patient is able to detect and distinguish different smells.
Patient is allergic to dust, which makes his eyes watery.
No ear problems detected, as the patient is able to hear and differentiate different sounds.
The patient is also able to distinguish different tastes.
Patient is able to chew and swallow food without any difficulty.
Patient has a clear vision and able to distinguish between different colors.
Patient is able to move his eyebrows and other facial movements.
The patient is able to move his jaw muscles effectively.
The patient is also able to communicate effectively using facial expressions.
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):
Lymph nodes neither tender nor swollen.
Thyroid gland not swollen.
No pain on skull and neck.
Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus):
Normal eye muscle movement as well as side vision.
Eye pupils react normal to light.
Extra ocular movements are normal with the eyes moving in the same direction.
Normal ocular fundus.
Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity):
No discharge from the ears.
Patient able to detect different sounds.
Tympanic membrane intact, pink in color, and it is not ruptured.
Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat):
The patient is able to detect and distinguish different smells.
Sinus is not swollen.
Lymph nodes not swollen.
Oral mucosa is reddish pink.
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):
Skin color also normal.
Normally reacts to touch and other stimuli.
Moist mucus membranes.
No lesions on scalp.
Short and clean nails.
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 varicose veins on the legs.
Palpation 3 + indicating a normal pulse rate.
Swollen leg joints due to Arthritis.
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):
Carotid bruit normal.
Normal jugular venous pressure.
Increased apical pulse rate due to hypertension.
Apical rate is 105 beats per minute at rest.
An S3 heart sound is present which indicates a heart disease.
Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds):
Symmetrical breath movements, which are demonstrated by the Thoracic cage.
Normal breathing patterns.
Tactile fremitus present on palpation.
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):
No deformity or swelling on spine.
No deformity on legs and hands.
Shoulders are also even.
Pain on joints due to Arthritis.
Swelling on ankles and knees.
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):
A flat and symmetric abdomen.
Negative rebound tenderness.
Active bowel sounds.
No enlarged organs.
Genitourinary System (deferred for purpose of this class)
Cognitive perception is normal and adequate.
No memory issues detected.
Adequate judgment and reasoning ability.
The patient has an increased appetite.
The patient takes a balanced diet and drinks enough water.
Patient has six small meals a day with light meals at night.
The patient also eats foods rich in fiber to increase his metabolism.
Normal digestion process.
Normal sexuality-reproductive pattern.
Patient has been married for the last 40 with his wife whom they have 4 biological children.
Pattern of Elimination
Normal bowel movement.
No report of constipation.
Increased bladder function.
No report of any diseases.
Pattern of Activity and Exercise:
Patient performs regular exercise as prescribed by his physician due to Arthritis to increase his movement patterns.
Patient takes regular walks and other recreation activities with his grandchildren.
Works at his home garden two times a week.
Pattern of Sleep and Rest:
Patient sleeps between 5 to 6 hours in a day as most of the time the patient is busy running his business.
Rest and sleep are inadequate during certain times due to the busy schedule.
Patient complains of being always tired.
Pattern of Self-Perception and Self-Concept:
Normal self-perception and self-concept.
Makes most of the important decisions in the family.
A member of other social and community organizations.
Very religious and believes in God and the value of life.
Summarize Your Findings
(Use format that provides logical progression of assessment.)
Situation (reason for seeking care, patient statements):
The patient has hypertension.
Patient reports having regular headaches, which he thinks, might be attributed to hypertension.
The patient is also suffering from Arthritis, which is becoming worse every day with increased pain at the joints.
The patient is always feeling tired and fatigued.
Background (health and family history, recent observations):
The patient has a family history of hypertension, which has also affected the patient.
The headaches experienced may be associated with hypertension due to inadequate control of this condition (Rhoads & Petersen, 2014).
The patient is also suffering from Arthritis, which has continued to worsen over time.
The patient performs yearly health check-ups.
Assessment (assessment of health state or problems, nursing diagnosis):
From the symptoms experienced by the patient, it is likely that the patient is experiencing complications associated with hypertension (Rhoads & Petersen, 2014). If hypertension is not effectively controlled, it may lead to other health issues, which are faced by the patient (Rhoads & Petersen, 2014). With the increased appetite and regular urine discharge, this may be a symptom of diabetes, which is associated with hypertension. The patient should be tested for diabetes and heart disease (Rhoads & Petersen, 2014).
Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education):
Patient needs to involve himself more in exercise to maintain his body weight and control his blood pressure level to prevent the complications associated with a poor control of blood pressure (McFarlane & Bakris, 2012).
The patient should also maintain his diet to prevent increasing his weight, which may pose more danger to his health. This includes foods low in cholesterol and fat (McFarlane & Bakris, 2012).
More information regarding how the patient can control his hypertension condition and Arthritis will help the patient to improve his overall health status (McFarlane & Bakris, 2012).
The patient should also effectively control his blood pressure level to prevent any negative complications associated with an ineffective management of this condition (McFarlane & Bakris, 2012).
McFarlane, S. I., & Bakris, G. L. (2012). Diabetes and hypertension: Evaluation and management. New York: Humana Press.
Rhoads, J., & Petersen, S. W. (2014). Advanced health assessment and diagnostic reasoning. Burlington, MA: Jones & Bartlett Learning.