Health History and Examination Essay

Neurological System ( spik for each onees, head injuries, dizziness, convulsions, tremors, weakness, numbness, titillating, trouble speaking, difficulty sw wholeowing, etc., medications) long-suffering is alert, awake and oriented. Denies headaches, head injuries, dizziness, seizures, tremors, migraine, difficulty in wrangle and sw eitherowing. No fib of falls. long-suffering does mention that he has numbness and tingling of fingers and toes occasionally. Takes Gabapentin 100mg by word of m out(p)h three times a daylight. Head and Neck ( distressingness, headaches, head/neck wound, neck inconvenience, lumps/ puffiness, surgeries on head/neck, medications) enduring denies neck or head injuries, denies swell or lumps on neck and head, Denies neck pain or headaches. Eyes (eye pain, blurred vision, history of crossed eyes, firing/ pompousness in eyes, watering, t heading, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications) diligent w sp ike heels eyeglasses that atomic number 18 with him. zygomorphous cataract surgery done in June 2013. tied(p) vision checks after surgery done in November 2013 and at mystify he is not on each medications at home. Ears (earache or some other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty earshot, environmental noise exposure, silliness, medications) No complaints of ear pain, infection, surgery tinnitus ascribable to noise, or vertigo celebrated. Not on any medications. bad of comprehend right ear further does not use a hearing aid. Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental c atomic number 18, medications) Denies discharge from nose and throat, denies comportment of sores or lesions in the mouth. Denies nose bleeds, bleeding gums, or sorethroat. No known allergies remark. Has f number and glower dentures that patient cleans with Poliden t tablets perfunctory. explanation of Tonsillectomy at shape up 7. Skin, sensory 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) long-sufferings skin color is ethnic. Has some gray hair b arely no alopecia. Has well groomed nails. Denies skin problems. Particular about role 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. marginal vascular and Lymphatic System (leg pain, cramps, skin changes in munition 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 ( toilet table pain or strictness, SOB, cough out, swelling of feet or manpower, family history of cardiac disease, tire easily, self-history of heart disease, medications) Denies any government agency pain or tightness. Denies shortness of jot 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 provided 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 course of study as outpatient and per patient results were habitual. Patient is taking aspirin 81mg orally daily, metoprolol 25mg orally daily, and Plavix 75mg orally daily. Thorax and Lungs (cough, SOB, pain on transport or expiration, chest pain with breathing, history of lung disease, smoking history, living/ working conditions that affect breathing, last T B skin test, flu shot, pneumococcal vaccine, chest x-ray, medications) Has occasional cough that could be due to change of climate. Denies shortness of breath or pain with breathing.Denies smoking and no history of lung disease is noted. immunised for Influenza and Pneumonia on 10/14/2013. Patient was in ER in March for cough and fever and x-ray of the chest showed no deviateities at that time. musculoskeletal System (joint pain stiffness swelling, heat, redness in joints limitation of political campaign muscle pain or cramping deformity of osmium or joint accidents or trauma to bones back paindifficulty with activity of daily living, medications) Denies any symptoms of joint problems and does not behave any medications at home. Patient is free lance and requires no assistance for activities of daily living. His wife and he pick up walks on a daily buttocks for 20 minutes. Gastrointestinal System (change in appetite increase or loss difficulty swallowing fodders not tolera ted abdominal pain nausea or vomiting frequency of BM history of GI disease, ulcers, medications) Denies any gastro-intestinal disease, ulcers, or diabetes. Consumes low sodium diet with no added salt three times a day and a bedtime snack. Includes plenty of vegetables and fruits in his diet. No swallowing problems noted.No complaints of nausea, vomiting or diarrhea noted. Patient has daily catgut movement and reports that it is brown in color. Denies use of stool softener or laxative. An Endoscopy and Colonoscopy was done in January 2014 and no abnormalities noted at that time. 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, higher up pubic region or low back) Denies pain or any urinary problems. Patient verbalizes increased frequency of urination due to Lasix. Patient wakes up twice at dark to urinate but he is cont inent of bladder. Per patient no prostatic problem noted. Last prostate exam was done in February 2014. Physical Examination(Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, drive and sensory assessments) Patient is awake, alert, and oriented with no memory loss. Patient is calm, cooperative and pleasant. Judgment is intact. Patients speaks clearly and in liberal sentences. No difficulty noted while speaking. No swallowing problems noted. Patient has a unassailable gait with well(p) strength. Sensations present in all extremities. Complaints of occasional numbness and tingling of fingers and toes but denies upon examination. Head and Neck ( experience the skull, shoot the breeze the neck, chat the face, touch the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland) Skull and neck are normal on examination. No deformities or hematoma noted. No lymph nodes identified on palpation. Adams apple present. Trachea is normal on palpation. Eyes (test ocular acuity, visual fields, extra ocular musclefunction, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus) Patient has eyeglasses with him. Patient is able to open and close his eyelids. Pupil is round and reaction to legerity is constriction to both eyes. Denies any blurring, watering, or tearing of the eyes. No redness or infection noted.Ears (inspect external structure, otocopic examination, inspect tympanic membrane, test hearing acuity) Hard of hearing right ear with no hearing aid. As per patient the physician had recommended hearing aid for the right ear but patient did not wish to use it. Otoscopic examination revealed normal ear canals and eardrums with minimal amount of earwax. Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat) Nose, mouth and throat are normal on examination. On palpation no pain noted to si nuses. The upper and lower dentures pop off well on the patient and do not become eject while talking or chewing. 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) No skin recession down or rashes or lesions noted on inspection of the skin. warp is normal to ethnicity. Skin is warm, dry and intact. Mucus membranes are pink and moist. Hair is gray and no alopecia noted. Texture of hair is soft to touch, no bring out ends noted.Kept short and clean. No ingrown nails or cracked nails noted. Nails are well groomed and pink in color. Patient verbalizes examining the skin and nails usual while taking a shower. Breasts and Axilla (deferred for purpose of class assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, shivers inspect legs, venous pattern, varicosities, beatniks, color, swelling, lumps) Bilate ral upper extremities are warm, symmetrical with bilateral radial pulses 2+. Bilateral lower extremities are warm, symmetrical without any discoloration. No varicose veins noted. Bilateral foot lever pulses 2+. A trace of dropsy is noted on both ankles and feet. Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium upchuck or lift, apical impulse auscultate rate and rhythm attain S1 and S2, any extra heart weighed downs, murmur) Carotid arteries are normal with pulse 2+. No jugular vein distension noted. Apical pulse is 82 beats per minute, BP of 150/80 mm of Hg. Heart sounds S1 and S2 are on auscultation. No murmur or extra heart sound noted. EKG shows aNormal Sinus Rhythm.Thorax and Lungs (inspect thoracic cage, symmetry, tactual fremitus, trachea palpate symmetrical expansion, percussion of anterior, lateral and posterior, abnormal breathing sounds) Thoracic cage is normal and symmetrical. No abnormality noted on palpation and percussi on. Breath sounds are clear and equal on auscultation in all lung fields. Respirations are even, regular and unlabored. Patient has occasional nonproductive cough relieved by cough medicine. Respiratory rate is 18/minute and Oxygen saturation is 99% on room air. Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, cut back of intercommunicate inspect shoulders for size, color, contour, swelling, mass, deformity, pain, mountain rank 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) Cervical spines are normal in si ze, no pain or deformities noted with full range of motion.Bilateral shoulders are equal in size, no swelling or mass noted. No pain noted on movement of shoulders. Bilateral elbows, wrists and hands are equal in size, with full range of motion and equal in strength. No deformities noted on inspection. Bilateral hips are equal in strength, no swelling or mass noted. No evidence of redness or injury noted. Sacrum is intact. Bilateral lower extremities with full range of motion and equal strength noted. No swelling or deformity noted. Bilateral ankles and feet noted with trace of edema. Gastrointestinal System (contour of abdomen, superior general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution auscultate bowel sound, percuss all four quadrants percuss border of liver-colored light palpation in all four quadrants muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness) Abdomen is flat and non-distended. Bowels sou nds present in all four quadrants. Abdomen soft and non-tender on palpation. Percussion revealed tympany in all four quadrants. Umbilicus is midline and inverted. Surface of abdomen smooth and even, with homogenised color. No lesions or surgical scars noted. Genitourinary System (deferred for purpose of thisclass)FHP opinionCognitive-Perceptual tropePatient is alert and oriented, no memory loss. Well educated, and has the talent to read, write and understand nurture. Patient uses eyeglasses for reading and is hard of hearing right ear. Nutritional-Metabolic PatternPatient eats a low sodium diet with no added salt three times a day with a bedtime snack. Home cooked food with vegetables and fruits included in the diet are his preferences. The patient or his wife prepares the food. The patient and his wife do the food shopping. Sexuality-Reproductive PatternThe patient has three children and 5 grandchildren. He is not enkindle in sexual activities but loves to spend time with his wife. Pattern of expulsionPatient is continent of bladder and bowel. Urinary frequency is increased due to effect of medication (Lasix). Pattern of Activity and ExercisePatient is independent in activities of daily living. He is not involved in ready exercise but walks daily for 20 minutes along with his wife. Pattern of Sleep and RestPatient usually sleeps for 6-7 hours at night with an afternoon nap for 30 minutes. Patient wakes up twice at night to urinate but goes right back to sleep with no difficulty. Patient denies use of sleeping pills. Pattern of Self-Perception and Self-ConceptPatient is well dressed and has self-complacency and respects others too. He leads a disciplined life with the ability to take care of himself and his wife. He is friendly with his neighbors and is an active participant in perform activities Summarize Your Findings(Use format that provides logical progression of assessment.) Situation (reason for seeking care, patient statements)Name Lawrence K ellyAge/Sex 72 years/MalePresenting complaints change magnitude swelling of ankles and feet, numbness and tingling of fingers and toes, and occasional cough. Background (health and family history, recent observations) History of present complaintsPatient complains of swelling of feet and ankles for 2 weeks with numbness and tingling of fingers and toes. daily cough for last one week. Past medical History Hypertension, MI, Hard of hearing (Right Ear). Medication historyLasix 40mg orally dailyAspirin 81mg orally dailyPlavix 75mg orally dailyLopressor 25mg orally dailyGabapentin 100mg orally three times a day sound judgment (assessment of health state or problems, nursing diagnosis) Mr. Lawrence Kelly 72 year hoary male presented with complaints of swelling of feet and ankles with numbness and tingling of fingers and toes for the past 2 weeks. insouciant cough for the past one week. He is alert, awake and oriented with steady gait. Hard of hearing in the right ear. His vital signs are BP150/80 mm of Hg, Pulse 82, RR 18/minute, and Temp of 98.4. No chest tightness or pain verbalized. Breath sounds are clear and equal in all lung fields. Abdomen soft, non-tender and non-distended. Bowels sounds present in all four quadrants. No difficulty in urination verbalized and color of urine is amber. pass edema noted on feet and ankles. Pedal pulses is 2+. Nursing diagnosisFluid Volume Excess manifested by edema of feet and ankles.Recommendation (diagnostic evaluation, review care, patient education teaching including health promotion education) Blood tests should be done including Comprehensive Metabolic Panel, Vitamin B12 Level, and BNP. X-ray Chest is recommended to find out if patient has CHFEchocardiogram could be repeated as it was done more than 6 months ago Teach the patient to monitor BP, Pulse, Intake and Output, and Daily Weights. discuss the patient to elevate the lower extremities on pillows to reducedependent edema Encourage the patient to read food lab els on the sodium subject area Avoid fried foods, canned and frozen foods (Nanda Nursing Interventions, 2012) Provide information about community services such as Heart subject matter at Barnabas Health, Phone No. 1-888-724-7123 (Barnabas Health, 2013).ReferencesBarnabas 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