Running Head Adult Health History
Adult Health History and Examination
Michelle Pierson, RN
Grand Canyon University
September 29, 2012
Health History and Examination
|Michelle Pierson |9/26/2012 |
|Client/Patient Initials: JP |Sex:F |Age: 62 | |Occupation of Client/Patient: Retired | |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): Neurologically JP is intact. She speaks clearly, denies headaches, dizziness, and weakness. She admits that | |she often forgets where she has left her car keys or glasses, but feels it is due to her busy lifestyle. | |Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): JP has chronic neck pain | |related to a career of dancing. In 2010 after an x-ray and a MRI she was diagnosed with torticollis. . At times, she needed to take Flexeril | |5mg orally as needed, and Lortab 5/500mg orally as needed, to alleviate spasms and pain. | |She sees now a chiropractor twice a month, and denies any problems for 2 years, since beginning her chiropractic regimen. | | | |Torticollis results in spasms of the sternocleidomastoid, trapezius, and other neck muscles, usually more prominent on one side than the | |other, caused by turning or tipping of the head (Kruer, 1994/2012). | | | | | |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):JP has Myopia. She wears glasses to correct this. She reports that her mother had Glaucoma, but| |denies having it herself. Her last eye exam was April 2012. | |Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise | |exposure, vertigo, medications): | | | |JP reports that her hearing is “better than good.” She feels this is due to her poor sight, and that her body has compensated for her loss. | |She has had no surgeries. She admits to having chronic sinus problems and sometime that causes her ears to hurt. | |Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore...