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Health History and Examination

Student Name: Date:

 

Client/Patient Initials: GH Sex: F Age:                      65
Occupation of Client: Retired social worker
Health History/Review of Systems
Neurological System

The patient does not have a history of traumatic conditions. However, she has been experiencing a persistent headache for the last few days. The patient does not suffer from dizziness, muscular weakness and episodes of convulsions. She denies the tingling sensation in the extremities. She does not have speech and communication difficulties.

Head and Neck

The patient has not had incidences of traumatic head, neck and back injuries. She does not suffer from pain, inflammation and a decreased range of motion in the neck. She does not have inflamed lymph glands. She does not take medications for neck and head problems and has not been surgically operated on.

Eyes

The patient does not have a history of eye conditions. However, her vision has become blurred of late. She denies pain, redness and burning sensation in the eyes. She does not wear corrective lenses though she has been subjected to a vision test twice.

Ears

The patient noted that she does not suffer from ear-related conditions including abnormal discharge, pain, ringing, and infections. She also noted that she does not suffer from hearing loss and does not take medications for ear conditions.

Nose, Mouth, and Throat

The patient does not have dental caries, mouth sores, inflamed sinuses and a sore throat. She also denies nose bleeding, and excessive nasal discharge. She does not take medications for oral and respiratory conditions.

Skin, Hair and Nails

The patient is free from skin conditions. She does not suffer from scarring, excessive dryness of the skin, rashes, lesions and bruises. The patient also denies itching and change in skin color. The hair is evenly distributed and she does not have signs of baldness. The nails [are pink in color and do not have an infection

Breasts and Axilla

She does not have abnormal discharge from the breasts. She also denies masses, lumps, pain and burning in the breasts. She has not had changes in breast skin color.

Peripheral Vascular and Lymphatic System

The patient does not have an edematous condition, she pain, swelling, and decreased range of motion in the hands and legs. She also denies incidences of inflamed lymph glands..

Cardiovascular System

The patient does not have a history of heart conditions. She denies pain in the chest, extreme fatigue, and edema. She has hypertension, which is well controlled with Lisinopril medication. Of late she has been experiencing extreme shortness of breath especially when engaged in physical activities. She also tires easily.

Thorax and Lungs

She has experienced increased incidences of shortness of breath. She does not suffer from respiratory symptoms such as a persistent cough, wheezing, and labored breathing. She used to smoke cigarettes but she stopped due to her health condition. She received a flu shot in 2015 and a pneumococcal vaccine in 2011.

Musculoskeletal System

The patient denies musculoskeletal symptoms including joint pain, stiffness, muscular aches, and a decreased range of motion. Her posture and gait are normal. She does not report severe blows and injuries on the back. Though she does not suffer from cramping, muscular pain, inflammation, bone deformities, and joint pain her ability to perform activities of daily living has decreased due to her age.

Gastrointestinal System

She does not consume large quantities of food. She does not report weight loss of significant changes in appetite. She denies gastrointestinal problems including abdominal pain, bloating, diarrhea, nausea and vomiting. She has not had incidence of swallowing difficulties, or severe change in bowel patterns.

Genitourinary System

She does not suffer from urinary problems like oliguria, hematuria, dysuria, polyuria, pain and burning during urination, and urinary incontinence.  She denies changes in urine color, lower back pain and lower abdominal pain.

Physical Examination
Neurological System

The patient does not present with signs of motor and sensory disorder and her cranial nerves are grossly intact.

Head and Neck.

There are no visible signs of injuries, bruises, on infection on the head and neck. The neck is flexible and no signs of thryromegaly are visible

Eyes  

The field of vision for this patient is normal. Her external eye structure is normal, extraocular muscles are functioning normally. The sclera is white and the pupils are not infected.

Ear:

The patient does not demonstrate hearing problems. Ears canals are open with no abnormal discharge. She has normal external ear structures.

Nose, Mouth, and Throat

There are no visible signs of a sore throat, inflamed sinuses, and nasal congestion.

Skin, Hair and Nails

The patient’s hair is evenly distributed. Her skin is brown in color, consistent and warm to the touch. The skin and nails are not cracked.

Breasts and Axilla (deferred)
Peripheral Vascular and Lymphatic System

The patient does not present with signs of varicose veins. The pulse rate is abnormal.

She does not have swelling and lumps on the skin.

Cardiovascular System

S/1 and S/2 present and normal. The patient’s heart rhythm is irregular.

Thorax and Lungs

She has normal lung and breath sounds. Thoracic cage symmetrical.

Musculoskeletal System

No deformities in the extremities and other body parts. She does not have a decreased range of motion.

Gastrointestinal System:

Auscultation of the four quadrants reveals normal bowel sounds. Abdomen non-tender. Abdominal skin color is consistent. No signs of masses, lumps or enlarged organs.

Genitourinary System (deferred)
FHP Assessment
Cognitive-Perceptual Pattern:

The patient has a high-level cognitive capacity. She can make rational decisions. She easily understands advice and follows direction. She has not experienced hearing though she states that she finds it had to hear whispers and faint sounds. She has been experiencing blurry vision in the past few days. Her concentration and memory have not changed much though she is old..   

Nutritional-Metabolic Pattern:

She takes at least two meals per day. She has also been taking vitamin and calcium supplements. She takes sufficient amount of water per day following the advice of her primary care provider.

Sexuality-Reproductive Pattern:

Sexuality and reproductive health assessment were not conducted for this patient

Pattern of Elimination

The patient demonstrates a normal pattern of elimination since she visits the toilet at least once daily. She does not suffer from abnormal changes in bowel sounds, inability to control bladder, diarrhea and constipation.

Pattern of Activity and Exercise:

The patient is rarely involved in physical exercises. She avoids strenuous physical exercises since due to shortness of breath.

Pattern of Sleep and Rest:

She sleeps for approximately seven hours during the night. She has not had significant sleep problems though at times she wakes early and finds it hard to initiate sleep.

Pattern of Self-Perception and Self-Concept:

She has never developed negative feelings and perceptions towards her body. She feels that she has accomplished most of the things she wanted in her life though she feels she could have done more.

Summarize Your Findings
Situation

Condition: blurred vision and shortness of breath

Patient statement: “I have visited due to blurry vision, headache and shortness of breath on exertion”

Background

Health history: she has a history of hypertension

Family history: mother had arthritis, and father had hypertension

Recent observation: the patient has experienced incidences of blurry vision, a persistent headache and tiring easily.

Assessment

Differential diagnosis:

Migraine: the presence of a persistent headache is the main symptoms of this condition (Schwedt et al. 2010).

Congestive heart failure: the symptoms of this condition are extreme fatigue, severe shortness of breath, trouble sleeping and tiring easily (Kaufmann, et al. 2012).

Main diagnosis

Primary hypertension: the symptoms that led to this diagnosis include the presence of irregular heartbeats, shortness of breath, a persistent headache, abnormal pulse rate and blurred vision (Kaufmann, et al. 2012).

Recommendation

Follow-up- the patient to follow-up in a month

Education:

Patient to consume healthy foods and engage in simple physical activities.

In case the health condition fails to improve she should seek medical attention

 

 

 

References

Kaufmann, W., et al. (2012). Primary Hypertension: Basic Mechanisms and Therapeutic Implications. New York, NY: Springer Science & Business Media.

Schwedt, T.J. et al. (2010). Headache. Cambridge, UK: Cambridge University Press.

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