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, Lymphatic, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems Student Name: Date: 10/3/2014
Client/Patient Initials: L. Kelly Sex: M Age: 72 years Occupation of Client/Patient: Security Officer (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): Patient is alert, awake and oriented. Denies headaches, head injuries, dizziness, seizures, tremors, migraine, difficulty in speech and swallowing. No history of falls. Patient does mention that he has numbness and tingling of fingers and toes occasionally. Takes Gabapentin 100mg orally three times a day. Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Patient denies neck or head injuries, denies swelling or lumps on neck and head, Denies neck pain or headaches. 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): Patient wears eyeglasses that are with him. Bilateral cataract surgery done in June 2013. Regular vision checks after surgery done in November 2013 and at present he is not on any medications at home. Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): No complaints of ear pain, infection, surgery tinnitus due to noise, or vertigo noted. Not on any medications. Hard of hearing right ear but does not use a hearing aid. Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): Denies discharge from nose and throat, denies presence of sores or lesions in the mouth. Denies nose bleeds, bleeding gums, or sore throat. No known allergies noted. Has upper and lower dentures that patient cleans with Polident tablets daily. History of Tonsillectomy at age 7. 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): Patient’s skin color is ethnic. Has some gray hair but no alopecia. Has well groomed nails. Denies skin problems. Particular about usage of moisturizing lotions after bath. Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications): Patient denies any problems with breasts and axilla. Does not perform self-breast examination. Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications): Denies leg pain, cramps or discoloration of arms and legs. Complains of occasional swelling on ankles. Takes Lasix 40 mg orally once a day. 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): Denies any chest pain or tightness. Denies shortness of breath or weakness. Complains of occasional cough relieved by Robitussin DM 10ml orally every 6 hours as needed. Patient is hypertensive and had an MI in 2005 but denies any history of Congestive Heart Failure. Family history shows that his father died of heart attack at age 75. Patient had an echocardiogram and stress test done last year as outpatient and per patient results were normal. Patient is...
References: Barnabas Health. (2013). Barnabas Health Heart Centers. Retrieved from http://www.barnabashealth.org/services/cardiac/index.htmlLifestyle and home remedies. Retrieved from http://www.mayoclinic.com/health/heart-failure/DS00061/DSECTION=lifestyle-and-home-remediesNanda Nursing Interventions. (2012). Nursing Interventions for Fluid Volume Excess. Retrieved from http://nanda-nursinginterventions.blogspot.com/2012/04/nursing-interventions-for-fluid-volume.html
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