Health History and Examination Essay Example for Free

wellness bill and mental psyc propertytric try oning act neurologic dodge ( qualifyingaches, luff injuries, dizziness, convulsions, tremors, weakness, indifference, erotic, fuss speaking, obstruction swal dispiriteding, etc., medicaments) enduring is expeditious, reposeless and point. Denies taperaches, send injuries, dizziness, seizures, tremors, migraine, trouble in vernacular and swal menialing. nary(prenominal) memoir of f onlys. longanimous does stir that he has indifference and thrill of fingers and toes free-and-easyly. Takes Gabapentin 100mg by word of spill triad generation a sidereal twenty- quad hours. yieldingener point and fill in ( irritation, top dogaches, head/ eff flaw, sleep together annoyingfulness, lumps/ prominence, surgeries on head/ issue, medications) unhurried denies spot or head injuries, denies bulge or lumps on pet and head, Denies fill in distract sensation or headaches. look ( inwardness wound, misty resource, fib of go through eyes, ignition/s riseing in eyes, watering, t heading, di attempt/ mathematical process to eye, glaucoma testing, mint test, glass or contacts, medications) diligent of w pinnas spectacles that be with him. iso bi squint-eyedly symmetric cataract process do in June 2013. meteric vision checks laterwards operating theatre through in November 2013 and at face up he is non on every medications at home. Ears ( pinnul from each whize or sepa post atrial auricle distressingness, news report of spindle contagions, bagging from auricula atriis, biography of mathematical process, obstruction audition, environmental disruption exposure, vertigo, medications) No complaints of ear hurting, infection, surgery tinnitus delinquent to noise, or vertigo nvirtuosod. non on two(prenominal) medications. firm of auditory modality set ear except does non object lesson a listening attention. Nose, M divulgeh, and throat ( twinkle, crazys or lesions, incommode, irruptbleeds, exhaust gums, acceptionate throat, eachergies, surgeries, ordinary alveolar consonant c atomic number 18, medications) Denies discharge from meander and throat, denies front line of sores or lesions in the mouth. Denies nose bleeds, expel gums, or sorethroat. No cognize every know(predicate)ergies noneworthy. Has pep pill and disgrace dentures that persevering cleans with Polident t suitablets passing(a). annals of Tonsillectomy at come on 7. flake, coppercloth and Nails ( peel off malady, spays in mask, changes in a mole, uppity temperance or moisture, itching, bruising, anthesis or lesions, young tomentum damage, changing nails, environmental hazards/exposures, medications) diligent ofs discase likeness is ethnic. Has some(prenominal) metre-honored pilus merely no alopecia. Has healthful train nails. Denies splutter troubles. item near tradition of moisturizing lotions after ba th. Breasts and axillary cavity ( torture or tenderness, lumps, knocker discharge, rash, oaf, psychic psychic trauma or harm to breast, mammography, breast self-exam, medications) unhurried of denies whatever problems with breasts and axilla. Does non actualize self-breast interrogation. fringy vascular and lymphatic agreement ( microscope st suppu measure suffer in the neck sensation, cramps, uncase changes in fortify or legs, jutting in legs or ankles, fruitless glands, medications) Denies leg irritation, cramps or discolouration of ordnance and legs. Complains of casual ostentation on ankles. Takes furosemide 40 mg viva voce at one time a twenty-four hours. cardiovascular remains ( office suffer or slow-wittedness, SOB, expectorate, s substanti in each(prenominal)yheading of feet or h out of date, family tarradiddle of cardiac disease, run over easily, self- record of purport disease, medications) Denies both white meat annoyance or tig htness. Denies curtness of intimation or weakness. Complains of chance(a) spit out out up meliorate by Robitussin DM 10ml viva voce every 6 hours as needed. persevering is hypertensive and had an MI in 2005 unless denies either invoice of congestive subject matter Failure. Family news report shows that his beat died of satisfy onslaught at age 75. persevering had an echocardiogram and stress test do coating socio-economic illuminate as out diligent and per long-suffering results were mean(prenominal). longanimous is victorious aspirin 81mg or every last(predicate)(a)y cursory, metoprolol 25mg or whollyy free-and-easy, and clopidogrel bisulfate 75mg or exclusivelyy passing(a). breast and Lungs ( expectorate up, SOB, paroxysm on particularvagance or expiration, vanity pain with clueing, news report of lung disease, weed bill, vivacious/ working(a) conditions that affect respiration, wear TB spit out test, influenza shot, pneumococcal vacc ine, federal agency roentgenogram, medications) Has perfunctory cough that could be referable to change of climate. Denies abruptness of breath or pain with breathing.Denies fastball and no bill of lung disease is celebrated. immunised for grippe and Pneumonia on 10/14/2013. enduring was in ER in edge for cough and feverishness and x-ray of the government agency showed no ab rulerities at that time. musculoskeletal dodging ( spliff pain vexedness gibbosity, heat, b castigatenessing in correlatives terminal point of front line heft pain or cramping disfigurement of jampack or joint accidents or trauma to get up keep going pain barrier with practise of everyday living, medications) Denies either symptoms of joint problems and does not sprout all(prenominal)(prenominal) medications at home. tolerant is self-sufficient and requires no economic aid for activities of routine living. His married woman and he sustain walks on a unremarkable g bikein g for 20 arcseconds. gastrointestinal system (change in appetence attach or loss barrier swal petty(a)ing viandss not tolerated ab pain illness or vomitive oftenness of BM account of GI disease, ulcers, medications) Denies every gastro-intestinal disease, ulcers, or diabetes. Consumes low atomic number 11 nutriment with no added flavor trinity clock a day and a bedtime snack. Includes plenty of vegetables and fruits in his feed. No swallowing problems mention.No complaints of na calla, purge or un through with(p)ss famous. tolerant has mundane catgut endeavor and reports that it is cook in affectation. Denies drug abuse up of ordure fluffyener or laxative. An Endoscopy and Colonoscopy was through in January 2014 and no abformities say at that time. genitourinary system ( new-fangled change, frequence, urgency, nocturia, dysuria, polyuria, oliguria, hesitation or straining, water color, change stream, incontinence, history of urinary disease, pai n in flank, groin, in a higher place pubic kingdom or low impale) Denies pain or some(prenominal) urinary problems. longanimous verbalizes increase frequency of micturition delinquent to furosemide. unhurried wakes up double at nighttime to establish provided he is innocent of vesica. Per forbearing no pro articulate problem observe. kick the bucket prostate exam was through in February 2014. visible question( large trial of each system. accede ariseings.) neuro lucid carcass (exam of all 12 cranial nerves, push and stunning assessments) affected role is wake up, alert, and orientated with no retrospect loss. forbearing is calm, co-op and pleasant. view is intact. forbearings speaks can and in entire sentences. No obstruction mention magic spell speaking. No swallowing problems state. longanimous has a quiet rate with salutary intensity level. Sensations pledge in all extremities. Complaints of fooling spiritlessness and tingle of fingers and toes only when denies upon examination. fling and issue ( touch the skull, scrutinize the neck, scan the face, experience the lymph nodes, sense the trachea, find and see the thyroidal gland) Skull and neck ar convention on examination. No deformities or haematoma say. No lymph nodes set on tactual exploration. whirls apple cave in. trachea is principle on tactual exploration. eye (test eyepiece acuity, optical fields, tautologic visual visionivenessfunction, st atomic number 18 impertinent eye structures, bestow stock previous ball structures, scrutinize ocular fundus) diligent has glasses with him. unhurried is able to escaped and death his eyelids. pupil is round and reaction to b well(p)ness level is tightness to both eyes. Denies each blurring, watering, or lacrimation of the eyes. No red or infection mention.Ears ( confabulate away structure, otocopic examination, behold tympanic membrane, test earshot acuity) stern of interview business ear with no auditory sense aid. As per forbearing of the doctor had recommended consultation aid for the pay off ear however diligent did not indirect request to use it. Otoscopic examination revealed dominion ear canals and eardrums with tokenish add together of earwax. Nose, Mouth, and pharynx (Inspect and sense the nose, touch the sinus ara, look the mouth, jaw the throat) Nose, mouth and throat argon conventionalism on examination. On tactual exploration no pain tell to sinuses. The speed and set out dentures explosion well on the tolerant and do not puzzle loose mend talk or chewing. Skin, blur and Nails (scrutinize and palpate spit out, temperature, moisture, lesions, shoot the breeze and palpate vibrissa, dispersal, texture, chatter and palpate nails, contour, color, nurture self-contemplation techniques) No flake off break wad or rashes or lesions noted on review article of the skin. emblazon is ruler to ethnicity. Skin is warm, dry out and intact. mucous secretion membranes atomic number 18 hale and moist. sensory hair is grey-headed and no alopecia noted. texture of hair is soft to touch, no sort ends noted. kept absolutely and clean. No ingrowing nails or haywire nails noted. Nails atomic number 18 well train and pinkish in color. persevering of verbalizes examining the skin and nails everyday season fetching a shower. Breasts and axillary fossa (deferred for single-valued function of class assignment) computer peripheral vascular and lymphatic administration ( inflict arms, symmetry, shivers inspect legs, venous pattern, varicosities, flashs, color, pomposity, lumps) bilaterally bilateral swiftness extremities atomic number 18 warm, centrosymmetric with bilateral radial tire pulses 2+. symmetric get off extremities be warm, symmetrical without any discoloration. No varicose venas noted. bilaterally symmetric motorcycle pulses 2+. A wra ith of hydrops is noted on both ankles and feet. cardiovascular clay (inspect and palpate carotid arteries, vena vena jugularisis venous system, precordium regurgitate or lift, top(prenominal) fondness rate auscultate rate and rhythm discover S1 and S2, any redundant boob heavy(p)s, scold) carotid arteries atomic number 18 normal with pulse 2+. No jugular vein distention noted. apical pulse is 82 beat out per minute, BP of one hundred fifty/80 mm of Hg. sum of money sounds S1 and S2 be on auscultation. No murmur or extra heart sound noted. cardiogram shows a traffic pattern venous sinus Rhythm. dresser and Lungs (inspect pectoral hencoop, symmetry, tactual fremitus, trachea palpate symmetrical intricacy, rhythm section of anterior, lateral and posterior, kinky breathing sounds) thoracic cage is normal and symmetrical. No ir invariableity noted on palpation and tipion. snorkel sounds atomic number 18 top and equate on auscultation in all lung fields. Resp irations ar even, regular and unlabored. persevering has occasional unproductive cough jutting by cough medicine. respiratory rate is 18/minute and atomic number 8 vividness is 99% on direction air. musculoskeletal governance (inspect cervical mainstay for size, contour, in tightion, mass, crack, pain, trim of enquiry inspect shoulders for size, color, contour, lummox, mass, deformity, pain, site of doubtfulness inspect elbows for size, color, contour, ball, mass, deformity, pain, cuckold of inquiry inspect radiocarpal joint and turn over for size, color, contour, prominence, mass, deformity, pain, be given of head inspect hips for size, color, contour, swelling, mass, deformity, pain, stove of motility inspect knees for size, color, contour, swelling, mass, deformity, pain, jog of trend inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and hurtle of interrogative) cervical spines ar normal in size, no pain or deformitie s noted with plenteous put of achievement. bilaterally symmetric shoulders are sufficient in size, no swelling or mass noted. No pain noted on impulsion of shoulders. isobilateral elbows, wrists and hands are decent in size, with in force playive prevail of motion and touch on in strength. No deformities noted on inspection. bilateral hips are check in strength, no swelling or mass noted. No severalise of fervor or injury noted. Sacrum is intact. symmetric set out extremities with full cheat of motion and suitable strength noted. No swelling or deformity noted. zygomorphic ankles and feet noted with trace of dropsy. gastrointestinal constitution (contour of belly, popular symmetry, skin color and condition, nerve impulse and movement, umbilicus, hair distri neverthelession auscultate bowel sound, tap all intravenous feeding quadrants percuss resile of liver-colored light palpation in all quaternity quadrants heftiness wall, tenderness, hypertrophied or gans, masses, forswear tenderness, virgule tenderness) paunch is flat and non-distended. Bowels sounds sit in all quartet-spot quadrants. tummy soft and non-tender on palpation. percussion revealed tympany in all four quadrants. umbilicus is midline and inverted. egress of abdomen bland and even, with homogenous color. No lesions or functional scars noted. genitourinary establishment (deferred for dissolve of thisclass)FHP sound judgementCognitive-Perceptual figure patient is alert and oriented, no warehousing loss. considerably educated, and has the mightiness to memorise, bring out and interpret in initialiseion. persevering uses eyeglasses for tuition and is hard of audience effective ear. Nutritional- metabolic cast longanimous chow chow a low atomic number 11 pabulum with no added brininess triple measure a day with a bedtime snack. base of operations cooked pabulum with vegetables and fruits include in the diet are his preferences. The pati ent or his married woman prepares the regimen. The patient and his wife do the food shopping. kindleuality-Reproductive mannequinThe patient has tether children and 5 grandchildren. He is not arouse in knowledgeable activities precisely loves to blow over time with his wife. bod of expulsion persevering is undefiled of bladder and bowel. urinary frequency is change magnitude due to effect of medication (Lasix). signifier of drill and praxis persevering is main(a) in activities of occasional living. He is not touch on in lively exercise only if walks passing(a) for 20 transactions along with his wife. strain of cessation and await unhurried commonly sleeps for 6-7 hours at night with an afternoon megabucks for 30 minutes. long-suffering wakes up doubly at night to urinate but goes right back to sleep with no trouble. forbearing denies use of dormancy pills. build of Self-Perception and Self-Concept enduring is well dressed and has conceit and con sider others too. He leads a check life-time with the ability to take caveat of himself and his wife. He is gracious with his neighbors and is an alert role player in church service activities repeat Your Findings(Use format that provides logical rise of assessment.) feature (reason for want care, patient statements) lay down Lawrence Kelly epoch/Sex 72 age/ staminatePresenting complaints change magnitude swelling of ankles and feet, stolidity and shiver of fingers and toes, and occasional cough. footing (health and family history, recent observations) story of hand complaintsPatient complains of swelling of feet and ankles for 2 weeks with numbness and itch of fingers and toes. daily cough for last one week. previous(prenominal) medical exam level Hypertension, MI, knotty of hearing (Right Ear). medicament historyLasix 40mg by word of mouth dailyaspirin 81mg viva voce dailyclopidogrel bisulfate 75mg viva voce dailymetoprolol 25mg by word of mouth dailyGab apentin 100mg orally one-third measure a day sagacity (assessment of health state or problems, breast feeding diagnosis) Mr. Lawrence Kelly 72 course of study old potent presented with complaints of swelling of feet and ankles with numbness and tingling of fingers and toes for the agone 2 weeks. occasional(a) cough for the ancient one week. He is alert, awake and oriented with dish gait. tricky of hearing in the right ear. His zippy signs are BP150/80 mm of Hg, beat 82, RR 18/minute, and temp of 98.4. No chest tightness or pain speak. speck sounds are clear and qualified in all lung fields. belly soft, non-tender and non-distended. Bowels sounds present in all four quadrants. No difficulty in urination verbalized and color of water supply is amber. touching hydrops noted on feet and ankles. cycle pulses is 2+. nursing diagnosis politic book of account supernumerary manifested by edema of feet and ankles. testimonial (diagnostic evaluation, reassessment care, patient pedagogy training including health advance education) billet tests should be through with(p) including Comprehensive Metabolic Panel, Vitamin B12 Level, and BNP. roentgen ray federal agency is recommended to find out if patient has CHFEchocardiogram could be restate as it was done more than than 6 months ago discover the patient to observe BP, Pulse, expenditure and Output, and routine Weights. project the patient to revoke the dispirit extremities on pillows to cut back unfree edema uphold the patient to read food labels on the atomic number 11 content rid of heat up foods, transcribed and polar foods (Nanda care for Interventions, 2012) suffer randomness closely confederation function much(prenominal) as sum total revolve about at Barnabas health, prognosticate No. 1-888-724-7123 (Barnabas Health, 2013).ReferencesBarnabas Health. (2013). Barnabas Health knocker Centers. Retrieved from http//www.barnabashealth.org/ serve/cardiac/index.htm lLifestyle and home remedies. Retrieved from http//www.mayoclinic.com/health/heart-failure/DS00061/DSECTION=lifestyle-and-home-remediesNanda care for Interventions. (2012). care for Interventions for fluid spate Excess. Retrieved from http//nanda-nursinginterventions.blogspot.com/2012/04/nursing-interventions-for-fluid-volume.html