Health History and Examination sample essay

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: Date:

Client/Patient Initials: C.B.Sex: FAge:
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):

Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications):

Occasional migraines. Meds: Phenergan PRN. Compliant with treatment 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):

Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications):

Hard of hearing in left ear. Wears a hearing aid daily.
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications):

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):

Chicken pox during childhood. Several skin tags removed on face and neck. Daily sunscreen 30 SPF Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications):

Peripheral 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 Leg Syndrome. No formal diagnosis made. Frequent muscle aches all over that require 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 heart disease, medications):

Family history of CHF. Pt has had a pacemaker since 2013.
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):

Pneumonia in the past. Current on Flu and Pneumonia vaccine. 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):

Joint pain and stiffness. Diagnosed with Rheumatoid Arthritis. 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):

Daily BMs
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):

Physical Examination
(Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments):
I let the patient identify the smell of toothpaste, and facial grimace noted
Patient able to read label of toothpaste tube
Using a penlight and approaching from side, I shine a light on a pupil and observed the response of the pupil. I did the same on the other side and the pupil constricted when looking at a near object, and dilated when looking at a distant object. Pupils are equally round and reactive to light.
D. TROCHLEAR AND ABDUCENS: (cardinal gaze )

I held a penlight 1ft. in front of the client’s eyes, and let the patient follow the movement of the light with the eyes only. Client’s eyes followed as I move the penlight but in late response.
Touched the lateral sclera of the eye to elicit blink reflex. To test light sensation I wiped a wisp of cotton over client’s forehead. Client has a positive corneal reflex, able to respond to light sensation, and sensitive to pain.
Client able to move eyeballs laterally
Client able to do different facial expressions such as smiling, frowning and raising of eyebrows; able to identify different tastes such as sweet, salty and bitter taste H. ACOUSTIC
Client able to hear loud and soft spoken words; able to hear ticking of watch in both ears. I.GLOSSOPHARYNGEAL
Client 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. VAGUS
Client able to swallow without difficulty
Client able to shrug shoulders and turn head from side to side against resistance
Client able to protrude tongue at midline and move from side to side 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):

Negative for lesions, scaling, tenderness, and masses
Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus):

Conjunctiva – normal color – pink over lower lids, white over sclera Sclera – white
Ears (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 canker sores or lesion

Throat: No lesions are redness noted
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: Clean and intact. No breakdown noted

Hair: Clean and dry. Mild dandruff noted
Nails: Trimmed and neat
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):

Arms symmetrical. Pulses palpable. Patient 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 abnormal heart sounds noted. Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds):

Respirations even and unlabored. No accessory 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 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):

Muscles developed without atrophy/hypertrophy. Arms & legs symmetric. No varicosities, or tenderness. Joints non-tender, without swelling, and with full ROM. Muscle tone & strength 5/5 bilaterally. Spine 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 border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness):

Abdomen firm and round. Bowel sounds x 4. General abdominal tenderness reported. Reported having regular BMs Genitourinary System (deferred for purpose of this class)
FHP Assessment
Cognitive-Perceptual Pattern:

Neurologic functions, Sensory experiences such as pain and altered sensory input all intact. Pt AAOx3
Nutritional-Metabolic Pattern:

Patient eats a regular diet and watches what she eats.
Sexuality-Reproductive Pattern:

Patient has had 8 children and 1 miscarriage.
Pattern of Elimination

Patient reported having daily BMs
Pattern of Activity and Exercise:

Patient walks around her neighborhood at least 3 times per week Pattern of Sleep and Rest:

Patient sleeps at least 7 hours a day. Patient denied using any sleeping aids. Pattern of Self-Perception and Self-Concept:

Patient is proud of her accomplishments as a wife, mother and grandmother.
She is also very proud of her cooking and the satisfaction it gives others. Summarize Your Findings
(Use format that provides logical progression of assessment.) Situation (reason for seeking care, patient statements):

Patient was voluntarily for me in completion of this project. Background (health 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 overall 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 education teaching including health promotion education):

I advised patient to continue eating well and to continue walking around her neighborhood. I expressed the importance of maintaining a healthy weight and remaining healthy.