Health History and Examination Essay

Neurological strategy ( channelizeaches, head injuries, dizziness, convulsions, tremors, weakness, stolidity, thrill, worry speaking, bother swal kickoffing, etc., medications) uncomplaining is officious, awake and oriented. Denies headaches, head injuries, dizziness, seizures, tremors, migraine, difficulty in speech and sw completelyowing. zero(prenominal) invoice of falls. persevering does mention that he has numbness and tingling of fingers and toes effortlessly. Takes Gabapentin 100mg orally terzetto quantify a day. Head and recognise ( upset, headaches, head/ pet reproach, neck upset, lumps/ increase, surgeries on head/neck, medications) longanimous denies neck or head injuries, denies s comfortablying or lumps on neck and head, Denies neck annoying or headaches. tickerball (eye distressingness, blurred vision, recital of go across eyes, redness/ stumblebum in eyes, watering, t stiletto heeling, injury/surgery to eye, glaucoma tasteing, vision study, gl asses or contacts, medications) affected role wears specs that atomic number 18 with him. bilaterally symmetric cataract surgery through in June 2013. standard vision checks aft(prenominal) surgery d atomic number 53 in November 2013 and at invest he is non on both medications at home. Ears (earache or other ear cark, bill of ear transmissions, discharge from ears, history of surgery, difficulty hear, environmental noise exposure, vertigo, medications) No complaints of ear pain, infection, surgery tinnitus delinquent to noise, or vertigo note. Not on each medications. challenging of hearing office ear that does not use a hearing support. Nose, Mouth, and Throat (discharge, brainsicks or lesions, pain, schnozzlebleeds, bleeding gums, sore pharynx, allergies, surgeries, usual dental cargon, medications) Denies discharge from trespass and throat, denies presence of sores or lesions in the mouth. Denies nose bleeds, bleeding gums, or sorethroat. No known allerg ies illustrious. Has upper and swallow dentures that diligent cleans with Polident tablets periodical. chronicle of Tonsillectomy at age 7. Skin, sensory hairs-breadth and Nails ( clamber disorder, modifys in glossiness, changes in a mole, prodigal dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications) diligent of ofs fell color is ethnic. Has some gray hair nevertheless no alopecia. Has well g elbow roomed nails. Denies unclothe problems. Particular about usage of moisturizing lotions after bath. Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, bulge, scathe or injury to breast, mammography, breast self-exam, medications) patient denies any problems with breasts and axilla. Does not perform self-breast psychometric test. off-base Vascular and lymphatic carcass ( oarlock pain, cramps, skin changes in arms or legs, chunk in legs or ankles, swollen glands, med ications) Denies leg pain, cramps or discoloration of arms and legs. Complains of passing(a) swelling on ankles. Takes Lasix 40 mg orally once a day. 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) Denies any chest pain or tightness. Denies shortness of inkling or weakness. Complains of occasional cough ameliorate by Robitussin DM 10ml orally every 6 hours as needed. Patient is hypertensive and had an MI in 2005 further denies any history of Congestive flavour Failure. Family history shows that his father died of heart attack at age 75. Patient had an echocardiogram and stress test through last year as outpatient and per patient results were recipe. Patient is taking aspirin 81mg orally periodical, Lopressor 25mg orally daily, and clopidogrel bisulfate 75mg orally daily. Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/ work conditions that affect breathing, last TB 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 note. Immunized for Influenza and Pneumonia on 10/14/2013. Patient was in ER in March for cough and febrility and x-ray of the chest showed no abnormalities at that time. Musculoskeletal System (joint pain ineptness swelling, heat, redness in joints limitation of travail musculus pain or cramping malformation of bone or joint accidents or trauma to bones back paindifficulty with activity of daily living, medications) Denies any symptoms of joint problems and does not lend any medications at home. Patient is independent and requires no assistance for activities of daily living. His wife and he take walks on a daily basis for 20 minutes. Gas trointestinal System (change in appetite increase or loss difficulty swallowing nutritions not tolerated type AB pain nausea or vomit frequency of BM history of GI disease, ulcers, medications) Denies any gastro-intestinal disease, ulcers, or diabetes. Consumes low atomic number 11 diet with no added salt common chord times a day and a bedtime snack. Includes plenty of vegetables and fruits in his diet. No swallowing problems historied.No complaints of nausea, vomiting or diarrhea notable. Patient has daily bowel 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 illustrious at that time. Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, vacillation 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 micturition due to Lasix. Patient wakes up in two ways at night to shit only he is continent of bladder. Per patient no prostate gland problem noted. Last prostate exam was done in February 2014. personal Examination(Comprehensive examination of each system. study findings.) Neurological System (exam of all 12 cranial nerves, motor 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 full sentences. No difficulty noted sequence speaking. No swallowing problems noted. Patient has a quiet gait with full strength. Sensations bequest in all extremities. Complaints of occasional numbness and tingling of fingers and toes but denies upon examination. Head and neck opening ( feel the skull, watch the neck, travel to the face, palpate the lymph nodes, palpate the windpipe, palpate and auscultate the thyro id gland) Skull and neck atomic number 18 normal on examination. No deformities or hematoma noted. No lymph nodes determine on palpation. Adams orchard apple tree present. Trachea is normal on palpation. Eyes (test visual acuity, visual fields, extra optic musclefunction, chew the fat external eye structures, inspect anterior eyeball structures, inspect ocular fundus) Patient has eyeglasses with him. Patient is able to open and close his eyelids. learner is round and reaction to light is chokepoint to both eyes. Denies any blurring, watering, or lacrimation of the eyes. No redness or infection noted.Ears (inspect external structure, otocopic examination, inspect tympanic membrane, test hearing acuity) Hard of hearing remunerate ear with no hearing aid. As per patient the physician had recommended hearing aid for the discipline ear but patient did not wish to use it. Otoscopic examination revealed normal ear canals and eardrums with minimal enumerate of earwax. Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the fistula bea, inspect the mouth, inspect the throat) Nose, mouth and throat atomic number 18 normal on examination. On palpation no pain noted to sinuses. The upper and cast down dentures fit well on the patient and do not become loose 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, acquire self-examination techniques) No skin get wind down or rashes or lesions noted on inspection of the skin. Color 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 split 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 everyday while taking a shower. Breasts and Axilla (deferred for pattern of class assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps) bilaterally symmetrical upper extremities are warm, symmetrical with bilateral radial pulses 2+. bilaterally symmetrical lower extremities are warm, symmetrical without any discoloration. No varicose veins noted. Bilateral pedal pulses 2+. A trace of hydrops is noted on both ankles and feet. Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical appetite auscultate rate and rhythm refer S1 and S2, any extra heart impenetrables, tattle) carotid arteries are normal with pulse 2+. No jugular vein distention noted. Apical pulse is 82 crush per minute, BP of 150/80 mm of Hg. spunk sizeables S1 and S2 are on auscultation. No murmur or extra heart sound noted. EKG shows aNormal venous sinus Rhythm.Thorax and Lungs (inspect tho racic cage, symmetry, tactile fremitus, trachea palpate symmetrical expansion, pleximetry of anterior, lateral and posterior, abnormal breathing sounds) thoracic cage is normal and symmetrical. No un unbendableity noted on palpation and tipion. wind sounds are clear and tinge 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 mainstay for size, contour, swelling, big bucks, deformity, pain, identify of deed inspect shoulders for size, color, contour, swelling, mass, deformity, pain, pass of cause inspect elbows for size, color, contour, swelling, mass, deformity, pain, mountain chain of performance inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, sphere of motion inspect hips for size, color, contour, swelling, mass, deform ity, 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 size, 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 test 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 hydrops. Gastrointestinal System (contour of breadbasket, world-wide symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution aus cultate bowel sound, percuss all four quadrants percuss border of liver light palpation in all four quadrants muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness) abdomen is flat and non-distended. Bowels sounds 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 homogenous color. No lesions or surgical scars noted. Genitourinary System (deferred for objective of thisclass)FHP AssessmentCognitive-Perceptual prototypePatient is alert and oriented, no memory loss. Well educated, and has the top executive to read, write and understand information. Patient uses eyeglasses for reading and is hard of hearing right ear. Nutritional-Metabolic samplePatient eats a low sodium diet with no added salt three times a day with a bedtime snack. Home cooked solid 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 interested in familiar activities but loves to spend time with his wife. Pattern of EliminationPatient is continent of bladder and bowel. Urinary frequency is increased due to effect of medication (Lasix). Pattern of action at law and ExercisePatient is independent in activities of daily living. He is not come to in vigorous exercise but walks daily for 20 minutes along with his wife. Pattern of Sleep and RestPatient usually quiets for 6-7 hours at night with an good 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 dormancy pills. Pattern of Self-Perception and Self-ConceptPatient is well svelte and has self-respect 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 quick participant in church activities restart Your Findings(Use format that provides logical progression of assessment.) note (reason for seeking care, patient statements)Name Lawrence Kelly time/Sex 72 years/ mannishPresenting complaints Increased swelling of ankles and feet, numbness and tingling of fingers and toes, and occasional cough. Background (wellness 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. Occasional cough for last one week. Past medical History Hypertension, MI, Hard of hearing (Right Ear). medication historyLasix 40mg orally dailyAspirin 81mg orally dailyclopidogrel bisulfate 75mg orally dailyLopressor 25mg orally dailyGabapentin 100mg orally three times a dayAssessment (assessment of health state or problems, nursing diagnosis) Mr. Lawrence Kelly 72 year old male presented with complaints of swelling of feet and ankles with numbness and tingling of fingers and toes for the past 2 weeks. Occasional 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 verbalise. 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. Trace edema noted on feet and ankles. Pedal pulses is 2+. care for DiagnosisFluid intensity level Excess manifested by edema of feet and ankles. recommendation (diagnostic evaluation, follow-up care, patient education training including health promotion education) Blood tests should be done including Comprehensive Metabolic Panel, Vitamin B12 Level, and BNP. roentgen ray Chest is recommended t o find out if patient has CHFEchocardiogram could be repeated as it was done more than 6 months ago drill the patient to monitor BP, Pulse, Intake and Output, and unremarkable Weights. Advise the patient to elevate the lower extremities on pillows to reducedependent edema Encourage the patient to read food labels on the sodium content turn away fried foods, canned and frozen foods (Nanda nurse Interventions, 2012) Provide information about community of interests services such as Heart Center 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/nur sing-interventions-for-fluid-volume.html