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Health Assessment 1
Health Assessment and Physical Examination
April Clahane
Jacksonville University, School of Nursing
NUR 343
October 10, 2008
Health Assessment 2
Biographical Data:
Date: October 2, 2008
Name: A.B.
Age: 51
Address: Fullerton, California
Gender: Female
Marital Status: Married
Race: White/ Caucasian
DOB: April 28, 1957
Birthplace: Fontana, California
Occupation: Inactive Registered Nurse, Accounts Payable for a Law Firm
A.B. is a 51-year-old, white female, married 15 years. She was a Neonatal Intensive Care
Nurse for 5 years and is currently the accounts manager for her husband’s law firm,
working 3 days a week.
Sources: A.B., seems a very reliable. She supplies her medical history as a self report.
Reason for seeking care: Wellness Check
History of Present Illness: No present illness.
Past Health History:
Childhood Illness: Patient had mumps at age 6 and chickenpox at age 8. Denies having
measles, rubella, pertussis, scarlet fever, rheumatic fever, meningitis, poliomyelitis, and
strep throat.
Accidents or Injuries: At age 26, bilateral tibial stress fractures as a result of teaching
high impact aerobic classes. No surgery required just a course of physical therapy for 3
months. Age 42, complaint of right neck and shoulder pain unrelated to an accident.
Patient felt it was more related to stress. Went through a 6 week course of physical
therapy with minor relief, then went to a Chiropractor and had weekly adjustments times
3 with complete relief.
Chronic Illness: No chronic illness but patient complains she has intermittent episodes
with reoccurrence of neck and shoulder pain relieved by the use of Over-the-counter
N.S.A.I.Ds, Chiropractic care and massages. Patient has presbyopia and uses nonprescription glasses for reading.
Hospitalizations: Patient was hospitalized for 2 days at St Joseph’s Hospital, Orange,
California in 1998 for fever times one month of unknown origin. TMAX 102 degree F.
All cultures were negative but liver enzymes were elevated. Hepatitis screening was
negative, and hepatic ultrasound showed an enlarged liver without masses. Patient was
placed on triple antibiotics and made a full recovery.
Obstetric History: Gravida 1/ Para 1/ Abortion 0
Immunizations: Patient states she had all her childhood immunizations. She cannot
recall her last tetanus. She states she had a TB skin test that was negative when she was
working as an RN in 1995.
Last Examination: August 2008- Full physical with Primary care Physician and yearly
pelvic examination with OBGYN. Pap screen and mammogram normal. March 2008, last
eye exam revealed a slight worsening of preobyopia which was considered normal for
patient’s age and the patient was showing the beginnings of a pterygium. Last dental
exam was April 2007
Allergies: Patient is allergic to sulfa.
Current Medications: Motrin 800mg PRN neck and shoulder discomfort. Vitamins and
herbal remedies.
Health Assessment 3
Family History:
A.B. is the younger of two children. Mother died 5 years ago. Father remarried. H/O
cancer, cardiac disease and alcoholism. Patient denies any other knowledge of family
history.
GENOGRAM
84
Heart Attack
70
Well
75
Cardiac Disease
75
Well
?
Alcoholism
Unknown
79
Well
?
Multiple
conditions
6 deceased sisters history unknown
69
Lung CA
Key
Alive Male
Deceased Male
Alive Female
Deceased Female
53
Review
Well of
51
Well
PATIENT
61
Spouse Well
Health Assessment 4
Review of Systems:
General Health: Patient states she stays active, walking 3-5 miles 3 times a week. She
enjoys working in her vegetable garden and she cleans her own house. She denies any
weight change, fatigue, weakness, malaise, fever, or chills. Patient states she has about 5
episodes of ‘hot flashes’ during the night and about the same amount during the day.
Skin: History of 3 basal cell carcinomas on the right lateral bicep, right deltoid, and right
upper back. 1996, 2001, and 2006. History of recurrent eczema on face: In the right eye
brow and bottom right corner of the mouth. No other history of skin disease. Denies hair
loss. Nails have no change. Use of minimal sunscreen.
Head: Denies any frequent or severe headache, dizziness, or vertigo. No h/o head
injuries.
Eyes: Patient has presbyopia., States, “ It is a little worse since my previous exam but to
be expected due to my age”. She wears non prescriptive glasses for reading. Patient was
diagnosed with the beginning of a ptyergium in the L. eye but has not had any treatment
to date. Patient c/o difficulty seeing at night while driving. Denies blurred vision, eye
pain, diplopia, redness, swelling, discharge, glaucoma, or cataracts. Last eye exam,
March 2008.
Ears: Patient denies c/o hearing loss, earaches, infection, discharge, tinnitus, or vertigo
Nose and Sinuses: Denies any unusually frequent colds, sinus pain, obstruction, nose
bleeds, or any changes in sense of smell. Complaint of runny nose when mowing the
lawn. Hired a gardener.
Mouth and Throat: Denies mouth pain, frequent sore throat, bleeding gums, toothache,
lesions in mouth or gums, dysphagia, hoarseness, voice change, tonsillectomy, or altered
taste. Has a gold crown on the upper left second molar as a result of broken tooth. Denies
any dental caries. Last annual dental exam and cleaning- March 2007. Patient brushes in
the morning and at night before bed. Flosses randomly when she feels particles caught
between her teeth. Wisdom teeth removed 1976.
Neck: Complaint of intermittent pain, ‘muscle tightness’ on the right side of the neck and
shoulder. Has associated headaches when neck pain flares. Denies limited motion, lumps,
swelling, enlarged or tender nodes, and goiter. Takes Motrin 800mg PRN neck
discomfort and seeks chiropractic care.
Breasts: Denies pain, lumps, nipple discharge, rash, disease, and surgery. Performs self
breast exam every 6 months. Denies tenderness, lumps, or swelling in the axillary region.
Last breast exam by medical practitioner-AUG 2008. Last Mammogram-Sept 2008.
Respiratory System: Denies history of lung disease: Asthma, emphysema, bronchitis,
pneumonia, and tuberculosis. Denies chest pain with breathing, wheezing or noisy
breathing, shortness of breath, cough, sputum, hemoptysis, toxin, or pollution exposure.
Is a non-smoker.
Cardiovascular: Denies any pain, palpitation, cyanosis, dyspnea upon exertion,
orthopnea, nocturia, edema, or history of murmur, hypertension, coronary disease, and
anemia. Denies any cardiac testing.
Peripheral Vascular: No coldness, numbness and tingling, swelling of legs,
discoloration in hands or feet, varicose veins or complications, no intermittent
claudication, thrombophlebitis, or ulcers.
Health Assessment 5
Gastrointestinal: Good appetite, denies any food intolerance, dysphagia, heartburn,
indigestion, other abdominal pain, pyrosis, nausea and vomiting, Had isolated incidence
of liver enlargement of unknown origin in 1998. Liver enzymes back to normal. No
jaundice or gallbladder disease. Has approximately 2 bowel movements a day, normal
color and consistency. Denies diarrhea or constipation and use of laxatives or antacids.
Urinary System: Denies urgency, dysuria, polyuria, or oliguria, hesitancy or straining,
narrowed stream. Has had 2 UTI’s , “When I was a teenager”, treated with antibiotics. No
other history of urinary disease, pain in flank, groin, suprapubic region, or lower back.
Occasionally has small amount of incontinence when coughs. Patient gets up once during
the night to urinate. Says she does kegels exercises when she thinks about it.
Female Genital System: Denies pain, vaginal itching, discharge. Onset of menstruation
at age 12. Experiences premenstrual pain: tender breasts, lower abdominal cramping, and
diarrhea with her periods. Last menstrual period was June 2008, prior to that was
February 2008. Has had dysmenorrhea with the last 2 menstrual periods. Started
menopause symptoms 4 years ago. Has ‘hot flashes’ at night and during the day. Takes
herbal remedies and vitamins. Last gynecological exam AUG 2008, included PAP test.
Sexual History: Presently in a monogamous satisfying intimate relationship with her
husband. Patient does not use contraception, husband had a vasectomy. Patient has one
child age 26. Denies any STD’s and HIV exposure.
Musculoskeletal System: Denies history of arthritis or gout. No joint pain, swelling,
deformity, limitation of motion, noise with motion. No muscle cramping, weakness, gait
problems or problems with coordination. No back pain, stiffness, limitation of motion, or
history of back pain or disc disease. Has intermittent episodes of pain in the right side of
the neck in the trapezius muscle radiating down to the deltoid muscle. Patient states, “My
neck and shoulder sometimes feels rock hard and stiff”. Patient uses N.S.A.I.Ds ,
chiropractor care and massage for relief of symptoms. No use of ambulatory aids.
Neurologic System: Denies seizure disorder, stroke, fainting, blackouts, weakness, tic or
tremor, paralysis, or coordination problems, disorientation, hallucinations, memory
disorders, or moodiness. 2001 to 2002 experienced depression related to sons near death
incident. Patient received psychological treatment and was on antidepressants for 2 years.
Hematologic System: No bleeding tendency of skin or mucous membranes, excessive
bruising, lymph node swelling, exposure to toxic agents or radiation. Has never received
a blood or blood product transfusion.
Endocrine System: No history of diabetes or diabetic symptoms, thyroid disease,
intolerance of heat or cold, change in skin pigmentation or texture, excessive sweating,
abnormal hair distribution, nervousness, tremors. Patient is going through menopause but
does not take any prescribed hormone replacement medications.
Health Assessment 6
Functional Assessment:
Self-Concept: Graduated from Golden West Community College School of Nursing in
1986. Worked as a neonatal intensive care nurse for 5 years, was laid off. Went to work
for her husband’s law firm doing accounts payable and billing. She also enjoys being an
independent consultant for Party Lite candles. Income is stable and allows for frequent
traveling which she and her husband enjoy. Has a house on the Colorado River and
enjoys boating in the summer. All their children are adults living outside the home. She
hopes to become a grandmother some day.
Activity/ Exercise: Able to perform ADLs independently. Enjoys walking 3 miles, 3
times a week. Her and her husband have a tandem bike they ride often. Patient stretches
her thighs and calves prior to walking and again when she returns.
Sleep/Rest: Wakes up at 6:30am for morning walk and goes to be around 9pm Monday
through Friday. Likes to sleep in on the weekends until about 8am. No problems reaching
REM sleep. Awakes once a night to use the bathroom and is able to go right back to
sleep. Feels rested when awakes. Finds it difficult to take a nap during the day. No use of
any sleeping aids.
Nutrition: 24 hr recall- Breakfast-homemade banana nut muffin with a cup of coffee.
Lunch-roasted chicken and hummus in a pita bread pocket with tomatoes and lettuce, an
orange and lemon seltzer water. Dinner- Went out for Mexican food, had chips and salsa,
a cheese enchilada, chicken taco, refried beans and spanish rice, a coke with lime. Patient
cooks most meals but her kitchen is under renovation so she has been eating out more
than normal. Has no food allergies.
Interpersonal Relationships: Has been married twice. First marriage lasted 10years.
Currently has been married for 15 years to her second husband. Patient says she is very
happily married and that her husband is her best friend and she can rely on him for her
emotional needs. She also has a lot of social interactions with friends and leads a bible
study in her home once a week. She sees her father about once a month for family
gatherings and has a strong close relationship with him. Her sibling lives 8 hours driving
distance away and they have a very strained relationship.
Coping and Stress Management: Deals with a lot of stress at work and with personal
affairs. Patient states it sometimes is overwhelming. Her walks and her devotional time
reading her bible help alleviate the stress. No major change in lifestyle in the past year.
Drug, Tobacco, and ETOH Use: No Recreational drug use. No prescription drug use.
Occasional over the counter N.S.A.I.D use for neck and shoulder discomfort. Drinks a
glass of wine at night 2-3 nights a week. Is a non-smoker.
Home Environment: Lives in a quiet safe neighborhood. Home is 60 plus years old and
is under renovation. No security system in place. Just replaced all the windows which are
more secure. Does not have a fire extinguisher in the house and has not discussed an
emergency evacuation plan with husband.
Occupational Health: Denies any work hazards or exposure to environmental pollutants
or toxins
Health Assessment 7
Perception of Health:
Patient views good health first and foremost as being happy with herself, and accepting
who she is. She has found this allows her to promote a healthy lifestyle which includes
daily exercise, sensible diet, and weight control.
Physical Exam:
Date: September 22, 2008
Height: 5 feet 7 inches
Weight: 129 lbs
BP: 110/68 L arm sitting. Temp 99.0 degrees F. HR: 84 bpm, regular @ L radial. RR 16
unlabored
General Survey: A.B. is 51-year-old white female. Alert and oriented x3, sitting on her
couch. She is relaxed and maintains eye contact with questions. No noted involuntary
body movements, able to stand without assistance, normal gait.
Skin, Hair, and Nails: skin color is pink uniformly, warm, dry, intact, and with good
turgor. Patient appears well groomed and clean. No lesions, birthmarks, edema noted.
Has striae, pale white in color on abdomen and hips from pregnancy. Has 3 scars
approximately 1cm round from removal of basal cell carcinomas: right bicep, deltoid and
upper right back. Has a dime sized indentation scar on left deltoid from small pox vaccine
as a child. Hair, normal distribution and texture, no pest inhabitants, no alopecia noted.
Patient artificially colors hair. Nails, appear normal, patient has artificial finger nails
colored with red polish. Toes nails: no clubbing, ingrowths, discoloration, or fugal
growth noted. Toe nail beds pink and firm with capillary refill is 2 seconds.
Head: Normocephalic, no lesions, lumps, scaling, parasites, or tenderness. Face is
symmetric, no weakness, no involuntary movements.
Eyes: Symmetrical OU. Fields of vision normal by confrontation test. Presbyopia
confirmed by a hand held vision screener w/o glasses. Cover uncover test negative for
fixation OU. Corneal light reflex symmetric. No phoria, ptosis, nystagmus, lid lag,
exopthalmos, reddening, or scleral icterus. Conjunctivae pink, ptergium noted in the left
eye. No periorbital edema noted, no excessive tearing, PEERLA, no exudate noted. Iris
blue/green in color. Frontal sinuses non tender to palpation
Ears: Pinna no masses, lesions, scaling, discharge, or tenderness to palpation. Patient has
double piercing on both lobules, white exudate extruded when palpated. Both ears are of
equal size bilaterally with no swelling or thickening. Tragus firm to palpation and without
pain. Canals clear with small dark amber colored cerumen noted in right canal, no
redness, swelling or discharge. Whisper test ‘pretty petals’ heard bilaterally and repeated
correctly.
Nose: No deformities or tenderness to palpation. Nares patient, mucosa pink, no lesions,
discharge. Septum midline, no perforation. No sinus tenderness. Able to distinguish 2
separate scents, orange and a rose with eyes closed and one nostril occluded with each
scent. Frontal sinuses non-tender to palpation.
Mouth: Lips are smooth and pink, slight scaling noted in right corner of mouth at the
demarcation line between lip and facial skin. Mucosa and gingivae pink, no bleeding,
plaques or lesions. Teeth are evenly spaced without protrusions. Gold crown noted to
Health Assessment 8
upper second molar, no fillings or dental caries noted. Uvula is midline, rises to
phonation. Tonsils intact 1+, tongue symmetric and protrudes midline, no lesions. Able to
move tongue in all directions. Gag reflex intact.
Neck: Full ROM, trachea is midline, no lymphadenopathy palpated over nodes. Thyroid
non-palpable, non-tender. No JVD noted at 45 degrees. No bruits noted by gentle
palpation, carotid pulses 2+. Able to lift shoulders with mild force placed upon them, felt
slight muscular discomfort with this action in the right side of neck and shoulder.
Spine and Back: Normal spinal profile, no scoliosis, lordosis, or kyphosis. Able to bend
and touch toes, bend from side to side without pain. Scapula bones equal bilaterally and
CVA non-tender to palpation.
Thorax and Lungs: AP diameter < transverse diameter. Chest expansion symmetric.
Tactile fremitus equal bilaterally. Lung fields resonant. Respiration is relaxed without use
of auxiliary muscles, RR 16. No tenderness on palpation, no lumps or lesions and color is
consistent with skin tone. Breath sounds equal bilaterally, no wheezes, cough, crackles,
stridor, ronchi or rales, or adventitious breath sounds.
Breasts: Shape is symmetric. Exam deferred.
Heart: Precordium, no abnormal pulsations, no heaves. Apical impulse noted at 5th
intercostal space in the left midclavicular line. Listened 1 full minute, rate 73. No thrills
noted. Auscultated heart with the diaphragm of the stethoscope. Normal S1 and S2
sounds Unable to detect S3 or S4 sounds, no gallops, murmurs. No pulse deficit noted.
Abdomen: Flat, skin smooth with noted striae running from umbilicus to pubis. No
lesions, edema, bulging masses, pulsations or scars. Umbilicus is midline and inverted.
Bowel sounds active in all 4 quadrants for 1 minute. No hyper/hypoactive bowel sounds
noted. Abdomen soft, no organomegaly noted, no masses or tenderness, no inguinal or
umbilical hernia noted. No tenderness with light or deep palpation. Patient slightly
ticklish.
Extremities: Color pink no redness, cyanosis, lesions, varicosities, swelling, pain. All
peripheral pulses present, 2+ and equal bilaterally. Symmetric leg and arm lengths. Has
full ROM of all extremities.
Musculoskeletal: TMJ joint no slipping or crepitation. Neck full ROM with tenderness
on right side as previously stated. Vertebral column no tenderness, or deformity (
kyphosis, lordosis, scoliosis) Flexion, extension, circumduction, pronation, supination,
eversion, inversion, adduction, and abduction performed easily and without pain.
Neurologic: Mental status, appearance, behavior, and speech appropriate. Patient A&O
x3. Able to use judgment and think cognitively, demonstrated by conversations during
the exam. Past and present memories intact. Cranial nerves 1-12 intact. No tremors,
seizures, weakness, vertigo, numbness or tingling. No dysphagia, dysphasia. Able to
distinguish sharp and dull sensations throughout the body with eyes closed. Able to
distinguish between hold and cold. With patient standing she performed the finger to
finger to nose accurately. While she remained standing, performed the Romberg test and
was able to stand and maintain posture and position for 20 seconds. The patient walked
down the hallway and back, gait smooth, rhythmic, and effortless, opposing arm swing is
coordinated. Was able to distinguish light touch, eye closed and was able to identify the
wisps of cotton on random skin areas. Stereognosis ( paperclip) and graphsthesia (#7)
identified with eyes closed. DTRs attempted, was only able to illicit the patellar response,
2+. Scored a 15 on the Glasgow Coma Scale.
Genitalia: Deferred
Health Assessment 9
Nursing Diagnosis:
1. Actual: Alteration in comfort related to chronic pain as manifested by right neck
and shoulder tenderness, stiffness, and associated headaches.
Interventions:
1. Takes N.A.S.I.Ds PRN neck and shoulder discomfort and for headaches.
2. Chiropractic care for neck and spine adjustments.
3. Massage and heat therapy PRN
2. Actual: Noncompliance, at risk for visual deficits related to ptergium as
manifested by continued growth on left eye and patient’s lack of seeking medical
treatment.
Interventions:
1. Review with patient what a ptergium is.
2. Explain the growth pattern of a ptergium and the potential effects to the
patient’s vision.
3. Offer resources to Ophthalmologists who are local and have experience with
the procedure for removal.
3. Actual: Ineffective health maintenance related improper protective skin care as
manifested by excessive sun exposure in the summer and history of 3 different
sites of skin cancer.
Interventions:
1. Explain the relationship between skin cancer and sun exposure.
2. Recommend the use of sunscreen with SPF70 or use of a product that has total
UV sun block.
3. Suggest wearing a hat or sun visor and a t-shirt when at the river and stay in
the shade as much as possible