Adult Health History and Examination
Health Assessment and Screening
Health History and Examination
Client/Patient Initials: LH Sex: F Age: 47
Occupation: Registered Nurse
Health History/Review of Systems
Neurological System headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, and difficulty swallowing etc., medication): Neurologically JP is intact. Alert ox3 clear speech with no hesitations, c/o headaches and dizziness occasionally, upon arising in the am. She admits being “little stressed to family situations” and rotating shifts (DAYS/NIGHTS). Suggested to seek EAP (Employee Assistance Program) at work Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications: LH has full ROM to neck and head, closes her eyes and able to hold her arms and hands out without swaying. LH takes Motrin 800mg for headaches. Motrin (ibuprofen) is a no steroidal anti-inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. This medicine may also cause serious effects on the stomach or intestines, including bleeding or perforation (forming of a hole). These conditions can be fatal and can occur without warning while you are taking Motrin, especially in older adults. Nursing Drug Handbook (2013) 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: LH has myopia and astigmatism. She wears glasses for correction and contact lenses for aesthetics, no familial history of glaucoma, last eye exam on Sept 12, with no problems. Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications: LH states “better than average.” “I can’t see, but I sure can hear”. Denies tinnutitis, or being subjected to loud noises. She has had no surgeries or infections. Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications: LH gag reflex intact, oral mucosa moist, pink intact. Teeth intact, cavities noted on 2 back teeth, last dental exam was Jan2012, with a cavity filled, discussed the need to floss more, she brushes daily and after meals. Reports frequent rhinorrhea and nasal congestion, during the spring and summer. She self-treats this with over the counter Claritin-D 10/200mg LH feels that she has seasonal allergies, she refuses allergy testing. LH states “I do not need to be poked to know I have hay fever”. Reinforced to LH the drug classification and side effects of Claritin D. The decongestant in Claritin-D is Pseudoephedrine sulfate, which is the synthetic salt of one of the naturally occurring dextrorotatory, diastereomers of ephedrine. It is classified as an indirect sympathomimetic amine, and is in the amphetamine class. Nursing Drug Handbook (2013) The American Dental Association recommends that adults brush their teeth two times a day. Research has shown that infections in the mouth may be associated with heart disease, stroke, diabetes, pneumonia and other health problems that are common in older adults (American Dental Association, 2012) Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, and rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications): LH has soft, supple warm skin. LH has old acne scarring over facial area stated “I had really bad pimples when I was younger and used to picked them, but I have not had any issues in years”. LH also has thinning hair “I have had had it for years”. Maternal History of Alopecia and thinning hair, LH mother started losing hair in teens. LH uses Rogaine shampoo 3 times a...
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