The author of this paper has performed a health assessment on an adult patient and will discuss the findings in this paper. The author will introduce the client, complete the health history, and physical exam. While summarizing the findings, the nursing diagnosis and the plan of care, will be discussed in order to help the patient achieve health goals. Keywords: health history, nursing diagnosis, health assessment, adult, physical exam, plan of care Patient: Helen Smith
5658 Purple Road
Mebane, North Carolina, 27302
Date of Birth: 11/2/1984
Birthplace: South Korea
Marital Status: Single
Source: Helen, reliable source
Reason for Seeking Care: General Physical Assessment
History of Present Illness: None, present for general physical assessment.
This is a 29 year old Asian female presenting for a general physical assessment. (Patient advised to follow-up with Primary Care Physician for more recent physical exam). The patient states no known complaints or illnesses at this time. The patient is a good health historian with appropriate interactions with examiner and staff. Ms. Smith will provide a reliable history for the examiner.
Childhood Illnesses: Patient had chicken pox prior to adoption, no history of measles, mumps, rubella, croup, or pertussis. No history of polio,
rheumatic fever, or scarlet fever. Accidents: None.
Chronic Illnesses: None.
Obstetric History: Gravida 0/Para 0/Abortions 0
Immunizations: Childhood immunizations are up to date. Last tetanus: “college sometime.” Last TB skin test: “college sometime.” Last Examinations: Yearly pelvic examinations; last physical exam at age 18, prior to college enrollment. Last vision test: April 2013, wears corrective lenses (glasses and contacts alternately). Never had EKG or chest x-ray. Allergies: Penicillin, Amoxicillin, Azithromax.
Current Medications: Multi-vitamin daily, low-estrogen type birth control, 1/day, for 13 years. Ibuprofen po prn headaches, Tums po prn indigestion, OTC Lactaid po prn. Family History: Patient was adopted at the age of 8 months and there is no known family history. Genogram:
Psychosocial: Patient currently lives with mother and works fulltime in a real estate office. Never married. Has lived in NC since age of 8. Sleeps well, 8-10 hours per night. Cigarette use and occasional alcohol use.
Review of Systems:
General Health: Reports usual health “good.” No recent weight changes, no weakness or fatigue, no fever, or sweats. Skin: No change in pigmentation or appearance in moles. No rash, pruritus, or lesions. No past history of skin disease. No excessive dryness or bruising. Nails: no change. Hair: no recent hair loss. Self-care: wears sunscreen “occasionally;” no use of tanning beds, no environmental hazards. Head: Patient reports temporal, throbbing, mild headaches 1/month, OTC 400mg po Ibuprofen relieves headaches. No history of head or neck injury, dizziness, vertigo, or syncope. No neck pain, lumps, or swelling. Eyes: No double or blurred vision.
No eye pain, redness, discharge, lesions, watering, blind spots, or inflammation. Denies night blindness and halos around objects. No history of glaucoma, cataracts, or eye injuries. No history of strabismus or diplopia. Wears both contacts and glasses, alternately. Self-care: last eye exam April 2013, no eye medications or drops used. Ears: No hearing loss or ear discharge. No recent earaches: no present infections; had occasional childhood ear infections. No tinnitus or vertigo. Self-care: no exposure to environmental noise; cleans ears with Q-tips every other day, last hearing test performed as a school age child. Nose: No discharge. Cold 1/year, mild. Treated and resolved with OTC medications. No sinus pain, nasal obstruction, allergy, or history of sinus infections. No complaints of altered smell. Epitaxis during winter months; no history of cauterizations. Mouth and Throat: No mouth pain, gum bleeding, toothaches, sores or lesions in mouth. No dysphagia, hoarseness, or sore throat. No altered taste. Has tonsils. Self-care: brushes teeth twice daily, occasional flossing, last dental exam January 2013, normal per patient. Smokes 3-5 cigarettes per day for approximately 9 years. Drinks occasionally in social settings. No dental appliances. Neck: No pain or limited neck movement. No lumps or swollen glands. Breasts: No pain, lumps, or nipple discharge.
No rashes, swelling, or trauma. No self breast disease history or surgery. Unknown family breast history. Axilla without tenderness, lumps, rash, or swelling bilaterally. Self-care: does not perform self breast exams, has never had mammogram. Respiratory: No history of lung disease, no difficulties breathing or chest pain while breathing. No wheezing, cough, or shortness of breath. No history of respiratory infections. Has “one cold a year.” Smokes 3-5 cigarettes per day with no complaints of cough. Has tried to quit “several times” without success. Self-care: No history of chest x-ray or pneumonia vaccine. Last TB skin test 2002, negative. Last influenza vaccination Fall 2012. Works in well ventilated office. Cardiovascular: No complaints of chest pain, cough, palpitations, cyanosis, pallor, fatigue, dyspnea with exertion. No orthopnea, paroxysmal nocturnal dyspnea, nocturia, or edema.
No history of heart murmur, hypertension, coronary artery disease, high cholesterol, or anemia. Unknown family history of heart disease. No previous EKG. No recent changes in weight, moderately balanced diet reported, smokes 3-5 cigarettes per day with plans to quit. Light exercise in the form of walking dog 1 mile/day. Occasional social alcohol consumption. No current cardiac medications. Peripheral Vascular: No pain, tingling, or numbness in legs. No swelling, leg cramps, coldness, discolorations, varicose veins, infections or leg ulcers. No skin changes or swelling in arms or legs. Legs are equal in length, no standing for long periods at work. Reports no “swollen glands.” Has “desk job.” Gastrointestinal: Appetite good with no recent changes. “Lactose intolerance.” Occasional, once monthly, heartburn, self treated with OTC po Tums, with relief. No abdominal pain, nausea, or vomiting. No history of ulcers, liver or gallbladder disease. No jaundice, appendicitis, or colitis. Bowel movements 1/day or 1/every other day without noted rectal bleeding or pain. No previous abdominal surgeries or x-rays. Self-care: takes prenatal vitamin daily. Diet recall-see functional assessment. Urinary: No dysuria, frequency, or urgency. No nocturia, hesitancy, or straining.
No flank pain, groin pain, or suprapubic pain. Urine yellow in color, no blood or history of kidney disease. Genitalia: Menarche at age 14. Last menstrual period August 28. Cycle: 28 days, duration 3-5 days with moderate flow. No dysmenorrhea. No vaginal itching, abnormal discharge, sores, or lesions. Sexual Health: Not currently in relationship. States no sexually activity in “over one year.” Uses birth control pills. Musculosketal: No history of arthritis or gout. No joint pain, stiffness, swelling, deformity, or limitation of movement. No muscle pain, bone pain, or weakness. Self-care: nightly dog walking for approximately 1 mile, without pain Neurologic: No history of seizure disorder, stroke, syncope, weakness, or tremors. No weakness, paralysis, or problems with coordination. No difficulties with swallowing or speaking. No numbness or tingling. Not aware of memory problems, nervousness, or mood changes. No depression, currently or in past. Patient reports temporal, throbbing, mild headaches 1/month, OTC 400mg po Ibuprofen relieves headaches. No previous head injuries, dizziness, or vertigo. No coordination problems. Denies suicidal ideation or intent now or during adolescence. No previous stroke, meningitis, or encephalitis. Hematologic: No bleeding problems in skin. No excessive bruising. No exposure to toxins. Has never had blood transfusion or IV drug use. Endocrine: No increase in hunger, thirst, or urination. No problems with hot or cold environments. No changes in skin or appetite, no nervousness.
Self-Concept: Graduated from high school and college (biology degree).
Currently works in real estate office, full-time. Lives with mother and raised as a Lutheran but does not currently attend church. States “honest and dependable.” Believes limitations are “smoking and weight.” Activity-Exercise: Typical day: wakes at 7am. Works “desk job,” and walks approximately 1 mile each night with small dog. No problems with daily activities. Hobbies are reading, puzzles, playing with dogs, and gardening. Sleep-Rest: Bedtime 11PM. Sleeps 8-10 hours without use of sleep aids. Nutrition: 24 hours recall: Breakfast-none. Lunch-turkey sandwich, chips, and soda. Dinner- homemade nachos with shredded chicken. Snacks- cookies, pretzels, and banana. This diet is typical of most days. Eats lunch at work and dinner with mother at home. Shares household grocery expenses with mother. Also share cooking responsibilities with mother. Dairy intolerance, takes “Lactaid when needed.” Alcohol: Occasional social alcohol use. Denies use of street drugs. Smokes 3-5 cigarettes daily, interested in quitting. Interpersonal Relationships: Describes family as “typical family.” Denies physical, emotional, or sexual abuse during childhood. No current romantic relationship. Coping and Stress Management: Housing adequate with heat and utilities. Lives in safe neighborhood. States “no household hazards” and wears seat belt at all times. Frequent travel outside of USA and North Carolina.
Perception of Health:
States “weigh is a slight problem” and “would like to quit smoking.” Expects healthcare providers to encourage weight loss and quitting smoking.
Height: 61 inches (5’1”). Weight: 135 pounds. BMI: 25.5 Waist circumference: 29 inches. BP: 113/78 in left arm, sitting.
Temperature: 37.1ºC, orally. Pulse: 75. Respirations: 16 breaths per minute, unlabored. General Survey: Helen is a 29 year old Asian Female, who articulates clearly, ambulates without difficulty and is in no distress.
Skin: Color pink, even pigmentation, with no suspicious nevi. Warm to touch, dry, smooth, intact, and even. Good skin turgor, no lesions. Hair:
Even distribution, thick texture, no lesions, or pest inhabitants. Nails: No clubbing or deformities. Prompt capillary refill with pink nail beds. Head: Normocephalis, no lumps, no tenderness, no lesions, no trauma. Symmetric. Face: Symmetric. No drooping, no weakness, no involuntary movements. Neck: Supple with full Range of Motion. No pain. Symmetric. No cervical lymphadenopathy or masses noted. Trachea midline, thyroid not palpable. No bruits. Eyes: Snellen chart-Right 20/20, Left 20/20, while wearing contacts. Fields normal by confrontation. Corneal light reflex symmetric bilaterally. Brows and lashes present. Diagnostic positions test shows EOMs intact. No ptosis. Conjunctiva clear, sclera white, no lesions. Pupils equal, round, reactive to light, and accommodation. Fundi: Red reflex present bilaterally. Vessels present in all quadrants without crossing defects.
Discs flat with sharp margins. Retinal background has even color and no hemorrhages or exudes. Macula has even color. Ears: Equal size and shape bilaterally, no swelling or thickening. Skin color consistent with facial skin color. Skin intact without lumps, lesions, or bruises. No tenderness. Targus and pinna firm, no pain with movement. No mastoid process pain. No swelling, redness of discharge in external auditory meatus bilaterally. Scant amounts of cerumen present, light brown in color and waxy in texture. Bilateral tympanic membranes pearly gray in color with light reflex and landmarks intact, no perforations. Hearing: Responds appropriately to conservation, whispered word heard bilaterally. Nose: Symmetric with no deformities or skin lesions. Nares patent. Pink mucosa with no discharge, lesions, or polyps. No septal deviation or perforation. Sinuses without tenderness to palpation. Mouth: Can clench teeth. Mucosa and gingivae pink with no masses or lesions. Teeth are present, with one permanent dental implant on lower right noted. Teeth are straight and in good repair.
Tongue is smooth and pink without lesions. Tonsils intact. Tongue protrudes in midline without tremor. Throat: Mucosa pink, no lesions or exudates. Uvula rises in midline on phonations. Tonsils present without swelling. Gag reflex present. Breasts: Symmetric with smooth skin and even color with no rash or lesions. Arm movement shows no dimpling or retractions. No nipple discharge, no lesions. Breast contour and consistency firm and homogenous. No masses or tenderness, no lymphadenopathy. Spine and Back: Normal spinal profile, no scoliosis, tenderness, or masses. No CVA tenderness. Full ROM. Thorax and Lungs: Inspection-AP < transverse diameter. Respirations 16/minute, relaxed and even. Palpation-chest expansion symmetric, tactile fremitus equal bilaterally without tenderness to palpation, no lumps or lesions. Percussion- resonant to percussion over lung fields, diaphragmatic excursion 4 centimeters and equal bilaterally. Auscultation-vesicular breath sounds clear over lung fields with no adventitious sounds. Heart: Neck-carotids 2+ and equal bilaterally. Internal jugular vein pulsations present when supine and disappear when elevated to a 45º position. Precordium- inspection, no visual pulsations, no heave or lift. Palpation-apical impulse in 5th intercostals space at left midclavicular line with no thrill. Auscultation-rate 75 beats per minute, rhythm regular, S1S2 are normal, not diminished or accentuated. No S3 or S4, or other extra heart sounds, no murmurs.
Extremities: Inspection-pink color without redness, cyanosis, or any skin lesions. Extremity size symmetric without swelling or atrophy in upper and lower limbs. Palpation-temperature is warm and equal bilaterally. All pulses present, 2+ and equal bilaterally with no lymphadenopathy. Abdomen: Inspection-abdomen soft and supple, symmetric with no apparent masses. Skin is smooth with no striae, scars, or lesions. Auscultation-bowel sounds present in all four quadrants, no bruits. Percussion-tympany predominates in all four quadrants, liver span approximately 7 centimeters in right midclavicular line. Splenic dullness located at tenth intercostals space in left midaxillary line. Palpation-Abdomen soft, no organomegaly, no masses, and no tenderness. Musculoskeletal: Joints and muscles symmetric with no swelling, masses, deformities. Normal spinal curvature. No tenderness with palpation of joints, no heat swelling, or masses. Full range of motion with smooth movement. No crepitus, tenderness. Muscle strength-able to maintain flexion against resistance and without tenderness. Neurologic: Mental Status-appearance, mood, and behavior appropriate. Alert and oriented to person, place, and time. No deficits in recent memory or remote memory noted.
I: Identifies coffee and peppermint.
II: Vision 20/20 left and right eye with peripheral fields intact by confrontation, fundi normal.
III, IV, VI: EOMs intact, no ptosis or nystagmus, pupils equal, round, react to light and
V: Sensation intact and equal bilaterally. Jaw strength equal bilaterally.
VII: Facial muscles intact and symmetric.
IX, X: Swallowing intact, gag reflex present, uvula rises midline without lateralization.
XI: Shoulder shrug, head movement intact and equal bilaterally.
XII: Tongue protrudes midline, no tremors.
Motor- no atrophy, weakness, or tremors. Gait smooth and coordinated, able to tandem walk, negative Romberg. Rapid alternating movements, finger to nose smooth and intact. Sensory- Pinprick, light touch, vibration intact. Stereognosis-able to identify key. Reflexes- normal abdominal, no Babinski sign, DTRs 2+ and equal bilaterally with down-going toes.
This 29 year old Asian female presents to me in good overall health. Patient states no current illnesses or complaints at present time. Patient currently takes two medication daily, birth control pills and multivitamin, and three medications as needed, Ibuprofen, Lactaid, and Tums. Patient maintains full-time job with benefits. At this time, patient wished to attempt quitting smoking and a weight loss plan. Patient has a good support of family, friends, and co-workers.
Patient demonstrates good hygiene by receiving once or twice yearly dental exams, yearly eye exams, yearly gynecological exams. Patient states adequate sleep throughout the week. Adequate food intake with moderate physical exercise daily.
Needs for Improvement:
Patient needs to quit smoking and decrease weight to a healthy weight for her height.
Ibuprofen po prn for headaches. Tums po prn for heartburn/indigestion. Would like to see patient enroll in a quitting smoking program within the next 3 months and add aerobic exercise to regimen.
1- Increased risk for skin cancer related to sun exposure as evidenced by lack of sunscreen use. 2- Risk for imbalanced nutrition: more than body requirements related to excessive intake in relation to metabolic need as evidenced by increased BMI. 3- Activity intolerance related to smoking as evidenced by decrease in exercise tolerance. 4- Knowledge deficit related to smoking as evidenced by 3-5 cigarettes per day smoker. 5- Actively seeking assistance related to achieving and altering health habits in order to move towards a high level of health as evidenced by seeking health assessment.
Patient is ready to quit smoking as has multiple strengths which will aid is success of goals. Patient is in need of some minor lifestyle changes which are easily attainable. The registered nurse (RN) encourages changes that will increase patients overall health. Patient has set achievable goals, with the assistance of the RN, such as smoking cessation and the need to increase exercise tolerance and activity. Patient will seek weight loss program to accompany her increased activity. Patient should continue prn ibuprofen, prn Lactaid, and prn Tums, as well as prescribed multi-vitamin and oral birth control pills. Sunscreen use is also suggested to patient whenever out doors. Patient is encouraged to follow up with primary care physician.
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