Health Assessment and history

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Indiana University, Bloomington *

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C325

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History

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Dec 6, 2023

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docx

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Health Assessment and History 1 Health Assessment and History

Health Assessment and History 2 History of Present Illness Patient K.S. is a 31-year-old female, Caucasian whose religious beliefs are Christianity. The patient is being seen today for her annual physical. The patient states she is not having any problems or pain currently. Patient confirms previous diagnosis of chronic ear infections during childhood. The patient confirms she had a spinal fusion of the L4-S1 vertebras at Hancock Memorial Hospital as an outpatient surgery in September of 2009. The patient confirms two hospital stays, 48 hours each, for the birth of her two children by Dr. Linton on January 16, 2017, and March 2, 2021, both at IU North Hospital. The patient states she had tubal ligation at IU North Hospital as outpatient surgery in August of 2021. The patient confirms she has had all her childhood immunizations for measles-mumps- rubella, diphtheria-pertussis, inactivated poliovirus, Hepatitis B series, and varicella. The patient confirms she is up to date on her tetanus-diphtheria immunization, she received the immunization in February 2020. Family History The patient’s paternal grandfather is still living, and her paternal grandmother died from a brain aneurysm at age 49. The patient’s maternal grandfather died of kidney failure at age 71 and her maternal grandmother died of heart attack at age 82.

Health Assessment and History 3 The patient’s father is 61 years of age and has heart problems. He is still living, and he has one sister that is still living. The patient’s mother is 60 years of age, has diabetes, obesity, and is still living. She has four siblings, three living siblings that are alive and one sibling that died of pancreatitis. Social History K.S. is married, lives in Wilkinson, and has been a Registered Nurse for 6.5 years. She lives with her husband and two children. She has one daughter six years of age and one son 23 months of age. Her family has a close relationship, they are supportive, and love doing things together. K.S. gets along with her friends and co-workers. She enjoys spending time with her friends. She does not smoke or use any illegal drugs. She will occasionally have an alcohol beverage, approximately four times a year. The patient enjoys reading, listening to music, getting pedicures, and playing with her children. Review of System Constitutional – Patient has no appreciable diseases, patient has been feeling good, and has no problems currently. Eyes – Patient states she has no vision changes, no pain, swelling, redness, watering or tearing of the eyes and eyes are not crossed; she has not had any eye injuries or surgeries. The patient does not wear glasses.

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Health Assessment and History 4 ENT – The patient denies any nasal discharge, congestion, nosebleeds, sinus pain, and allergies, The patient does not wear hearing aids, the patient denies any changes in her hearing, and has had no vertigo. The patient has no discharge, ringing, buzzing, swelling, or pain in her ears. The patient had past ear infections during childhood. The patient does not have hoarseness, difficulty swallowing, no sore throats, no changes in taste or smell, no bleeding gums, or toothaches. Patient has no sores, or lesions in the mouth. Patient has never smoked. Skin, Hair, and Nails – Patient has no past skin diseases, no itching, no bruising, no skin rash or lesions, no recent hair loss. The patient wears sunscreen when outside, does not use tanning beds, and uses lotions daily. Head, Face, and Neck – Patient occasionally has migraines that are treated with Amerge and over the counter analgesics. She has not had any head injuries or dizziness. The patient has no neck pain, no lumps or swelling in the neck, and no previous head or neck surgery. Respiratory – Patient denies shortness of breath, chest pain, or coughing. The patient does not smoke. The patient has no history of lung disease. Cardiovascular – Patient denies chest pain, shortness of breath, coughing, or swelling of the feet and legs. Patient sleeps with one pillow. The patient does not tire easily. The patient has no history of heart disease. Neurological – Patient denies dizziness, seizures, tremors, numbness, or tingling. Patient does not have any trouble swallowing or speaking. Patient has no weakness in any body parts or previous head injury. Patient has occasional headaches. The patient has no history of stroke, meningitis, congenital defects, or alcoholism.

Health Assessment and History 5 Breast and Axillae – Patient denies, pain, swelling, trauma, discharge, and rashes of the breasts. Patient states she has not felt any lumps during self-breast examination. Endocrine – Patient denies any history of diabetes or thyroid disease. Patient states no changes in appetite, no unusual weight loss or gain, no heat or cold intolerance, no excessive sweating, no skin changes, no nervousness, or tremors. Gastrointestinal – Patient denies any changes in appetite. Patient states she has no abdominal pain, no difficulty swallowing, no nausea, or vomiting. The patient has bowel movements 1 time per day. No previous GI diseases Genital Urinary – Patient denies pain, frequency, or urgency with urination. Patient reports no sores or lesions. Patient has been pregnant 3 times. Patient has 2 children, both pregnancies were normal. Patient had a tubal ligation in August 2021. Patients menstrual cycle last approximately 5 days. The patient first started her period at age 13. Musculoskeletal – Patient denies pain in joints, stiffness, cramping or muscle pain. Patient states she has no limitations, no swelling, heat, or redness in joints. No deformities. The patient had back surgery in September of 2009 but denies any back pain currently. Psychology – Patient states she has had no changes in mood, and she is happy. Objective Data

Health Assessment and History 6 General appearance – Alert and oriented to time and place, clean, well groomed, dressed appropriately for the season, happy and calm, clear speech, steady gate, overweight, facial features symmetrical, erect posture, and sitting straight. Vitals: Temp:98.5 F Pulse:72 Resp. Rate: 16 BP: 122/80 O2 sats: 100% on room air. Weight 150 lbs. Height 5’ 4”. Eyes – Patient has 20/20 vision in both eyes without glasses, conjunctivae and lids are normal, pupils are equal, round, reactive to light, accommodation, optic disc sharp and flat, vessels intact, macula normal, and lacrimal glands no blocked. Eyes and eyebrows are symmetrical, and full eyelashes. ENT – External ears are normal, symmetrical, no swelling or thickening, no lesions or deformities, no cerumen, tympanic membranes intact, normal color with good movement, no inflammation or fluid, hearing intact bilaterally. External nose is symmetrical, no deformities or inflammation, no lesions, clear nasal cavity, no deviations, can breathe evenly through both nostrils, no pain or swelling in the sinus areas. Lips are moist, pink, no cracks or lesions, no broken teeth, gums pink and moist, buccal mucosa pink and shiny, palate and uvula pink and moist, tonsils 2+ pink and moist, tongue pink is pink and moist, no breath odor, and no lesions or swelling in the mouth. Skin, Hair, and Nails – Skin is warm, dry to touch, normal pigmentation, color is appropriate for race, smooth skin texture, no thickening or edema, no lesions, or deformities. Hair is blonde, fine, full, and even distribution, and no lesions or infestations on the head. Nails are pink, round, symmetrical, even distribution, capillary refill is normal.

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Health Assessment and History 7 Respiratory – Thoracic cage is symmetrical, no deformities, skin color appropriate for race, no skin lesion or breakdown, nail bed pink, patient is sitting straight, relaxed and calm, chest expansion is symmetrical and smooth, clear auscultations bilaterally with no abnormal sounds, skin is warm, dry, and intact, normal tactile fremitus, normal and effortless respiratory, no distress, no pain or tenderness of trachea, no lumps or masses, percussion over lung fields was low pitched, clear, and hollow. Cardiovascular – S1, S2 normal rhythm, no murmur, no rub, no abnormal or carotid bruits, carotid arteries moderate, external jugular veins collapsed, supine and internal jugular veins not visible with bed elevated at a 90-degree angle, rate and rhythm within normal limits, no irregularities, chest wall pulsations and heave equal and unlabored on both sides, apical pulse in fourth intercostal space at maximal point of impulse. Skin was intact, warm, dry, no lesions, and color appropriate for race. Breast and Axillae – Breasts are symmetrical bilaterally, no rashes, edema, lesions, tenderness, or discharge bilaterally. Skin is smooth, and even color bilaterally. Nipples are symmetrical and protrude normally. Both breasts move up symmetrically during retraction. No enlarged or tender lymph nodes. Endocrine – Preauricular lymph nodes are non-tender and symmetrical bilaterally. Superficial, posterior cervical, and deep cervical chain lymph nodes are non-tender and symmetrical bilaterally. Submandibular, submental, supraclavicular are non-tender and symmetrical bilaterally. Gastrointestinal: Umbilicus is midline, skin is smooth with silvery white stria, color is even and appropriate for ethnicity. Bowel sounds are equal in all four quadrants, no bruits heard. Abdomen

Health Assessment and History 8 is soft, non-distended, non-tender, and no masses. Liver size appears within normal limits, no liver nodularity or masses, no splenomegaly, no distended bladder, no changes felt in the kidney. No rebound tenderness, no rashes, lesions or bruising on the abdomen. Genitourinary: Skin color is even, labia minor is pink and symmetrical, labia majora is symmetric, plump, and well formed. Clitoris is midline, ureteral opening appears slit like and is midline. Perineum is smooth. Musculoskeletal : Normal alignment, mobility and no deformity of head and neck, spine, ribs, pelvis; normal ROM and 5/5 strength in all extremities except compared to 4/5 strength in LLE, no joint enlargement or tenderness; no clubbing, cyanosis, petechiae, or nodes of digits and nails; gait and station deferred because patient supine. Neurologic : Cranial nerve I is intact: patient can smell familiar scent. Cranial nerve II is intact: patient sees 20/20 bilaterally. Cranial nerves: IIII, IV, and VI are intact: pupils are equal, reactive, and accommodative. Cranial nerves V and XII are intact; muscles are equally bilaterally, able to feel light touch, able to smile, frown, close eyes tightly. Cranial nerve VIII is intact: the patient can hear normal conversation and passed the whisper test. Cranial nerves IX -XII are intact: uvula and soft palate rise in midline, tonsillar pillars move medial, no wasting or tremors of the tongue, tongue protrudes midline, patient lingual speech appropriate. Muscles are normal size for age and symmetric bilaterally. Strength and tone are even resistance to movement, symmetric, 2+ reflexes in biceps, triceps, and quadriceps bilaterally. Able to feel light touch, pain (pin prick), and vibration; normal finger-to-nose, normal heel to shin test. Normal stereognosis and

Health Assessment and History 9 graphesthesia. Romberg and Pronator test normal. Normal gait, patient able to walk in a straight line and stay balanced. Patient is alert and oriented to person, time, and place. Mental Status Exam: Patient is alert and oriented to time, place, season, and self. Memory is intact to recent and past events. Patient is calm, does not show any signs of anxiety, depression, or aggression. Summary Patient came in for a yearly examination. Patient is 5’3”, 159 pounds, with a BMI of 28. The patient has a steady gate, full range of motion, erect posture, and no physical abnormalities. Patient was alert and oriented to time, place, season, and self. Patient was calm and happy. The patient was well groomed, dressed appropriately for the season, and clothes were clean. Her skin color was appropriate for race. Talked with the patient about the importance of maintaining an appropriate weight and good nutrition. Encouraged the patient to continue her weight loss program. Patient is to return in one year. If the patient has any problems or concerns before then the patient will call the office. Reflection

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Health Assessment and History 10 The health history assessment was conducted on K.S. on April 3 at approximately twelve o’clock pm. at Saxony Hospital. Since I was able to perform the examination in a medical office at work, I feel that this helped make the experience more realistic. K.S. is a 31-year-old female married with two children. Informed consent obtained and applied the principle of privacy and confidentiality in the interview. Some communication skills I used during the interview were speaking in a normal non-condescending voice, used non- medical jargon so that the patient could understand what was being said, introduced myself, reviewed and summarized the examination with the patient. During the interview process I asked K.S. open-ended questions when I needed her to elaborate on her medical history and to gain further details and closed-ended questions when I needed specific answers allowing the communication to remain therapeutic. There were very few barriers of communication that were experienced during the interview and examination. The only barrier that I experienced was that at times K.S. was vague. I overcame this barrier by asking K.S. more open-ended questions and asked her for more clarification. I enjoyed building a trusting relationship with K.S. during the interview process. This allowed K.S to feel relaxed and calm through the examination. I did not encounter any communication barriers and K.S. was comfortable speaking about her health history and asking questions throughout the examination. The interaction and examination went well and was a more realistic experience for me due to being able to perform the assessment in an examination room. I was able to use all the skills that I learned in the lab and the proper equipment in the medical office.

Health Assessment and History 11 I wouldn’t alter my approach; I feel my approach was good. The challenges that I need to overcome are being more confident in my ability, becoming more proficient during the assessment to make it effortless, smoother, and quicker. I will continue to use the skills that I have learned in the classroom and in lab to enhance my skills.

Health Assessment and History 12 References Santrock, J. (2018). Life-Span Development (17th ed.). McGraw-Hill Higher Education (US). https://ambassadored.vitalsource.com/books/9781260166323 Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (Eds.). (2009). Fundamentals of nursing (7th ed.). Elsevier Mosby. Asif, T., Mohiuddin, A., Hasan, B., & Pauly, R. R. (2017). Importance Of Thorough Physical Examination: A Lost Art. Cureus , 9 (5), e1212. https://doi.org/10.7759/cureus.1212 Weber, J. R., & Kelley, J. H. (2013). Health assessment in nursing . Lippincott Williams & Wilkins.

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