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NRS-434VN Health Assessment Essay
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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: Date: August 27th, 2014
Client/Patient Initials: LLB Sex: Female Age: 80
Occupation of Client/Patient: Domestic Engineer
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 denies any head injuries, headaches, convulsions, tremors, numbness, tingling, difficulty speaking or swallowing
Patient denies taking any medication in correlation to her neurological system
Patient states, “When I get up sudden I have to wait a moment because I get dizzy.”
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications):
Patient denies any problems in the head and neck but states, “When I travel I bring a special pillow because my neck gets sore on the wrong pillows.”
Patient denies taking medication.
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 states she has a history of dry macular degeneration and it is being well controlled.
Patient uses special eye drops for her eye disease.
Wears corrective lenses. Admits to blurred vision occasionally.
Negative glaucoma testing 02/15/2014
Eye surgery in relation to the macular degeneration 08/13/2013
Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications):
Patient denies any ear problems
Last eye infection was over 10 years ago.
No discharge noted from ears
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications):
Lips pink, mucous membranes pink and moist
No discharge or foul odor noted
No history of nosebleeds, bleeding gums, allergies or surgeries on nose, mouth or throat.
Lymph nodes barely palpable
Patient had 4 wisdom teeth removed at age 20
Patient states she flosses daily, and brushes her teeth twice a day with sensodine.
No dentures noted
No missing teeth.
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 is flawless (I wish I age as beautiful as my grandmother).
Patient denies any skin disease, any changes in skin, excessive dryness, moisture, itching, any bruising, rashes
Patient has thinning hair. Patient states, “My hair started thinking in my late 50s, now I keep it short so people don’t notice all the hair I’ve lost.”
Patient moisturizes skin twice a day and reapplies with sun exposure.
Patient uses protective clothing and hats in the sun
Patient has an ingrown nail on her left big toe that causes discomfort and goes to a podiatrist to get it looked.
Patient does her pedicure every two weeks to have the nail trimmed by professionals.
Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications):
Patient denies any breast problems
Last mammogram 06/07/2014
Monthly self breast exam
No medications
Patient states, “They just aren’t as perky as they use to be.”
Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications):
No complaints of leg or ankle pain, cramps, swelling
No swollen glands
No medication
Patient does have varicose veins in legs and arms
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 cardiovascular problems noted
Patient states she takes a baby aspirin daily as prescribed by her doctor
Patient walks daily for a minimum of 30 minutes.
No self or family history of heart disease
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 cough, SOB or pain while breathing
No history of lung disease
Past smoker of 10 years, Quit when she was 40 years old.
Yearly flu shot
Pneumococcal vaccine within the last 5 years
Last chest X RAY 04/08/2014 Negative findings
NO medications
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 and back pain noted after long days working at the Church and in the garden, particularly when in one position for long periods.
Limited range of motion in rotator cuff , performs exercises as instructed by physical therapist
No accident or trauma to bones
Performs activities of daily living independently, just slower.
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 has regular daily bowel movements, takes fiber to help
No change in appetite
NRS-434VN Health Assessment Essay
