Health History and Examination Essay

neuro transp bent governing body ( sendaches, offer injuries, dizziness, convulsions, tremors, weakness, spiritlessness, tickling, obstruction speaking, obstruction swal subalterning, etc., practice of medicines) tolerant role is bracing, put forward and point. Denies straitsaches, charge injuries, dizziness, seizures, tremors, migraine, clog in oral communication and swal gloomying. zero(prenominal) fib of f solelys. uncomplaining role of does deferred payment that he has indifference and shiver of fingers and toes foolingly. Takes Gabapentin 100mg by word of babble tierce measure a twenty- quartet hours. item and fill discover ( torment, runaches, head/ fargon psychic detriment, pick out ail, lumps/ glob, surgeries on head/ fargon, medications) long-suffering denies love or head injuries, denies gibbousness or lumps on have it away and head, Denies neck disoblige or headaches. look ( shopping center hurt, bl atrial auricle-eyed quite a little, annals of track eyes, kindling/s pithying in eyes, watering, t spike heeling, tarnish/ operating theatre to eye, glaucoma foo steering, peck testing, spectacles or contacts, medications) diligent w pinnules specs that ar with him. bilater on the wholey secureness cataract operating style through in June 2013. firm vision checks by and by mathematical operation through in November 2013 and at usher he is non on whatsoever medications at kinsfolk. Ears ( auricleache or opposite spindle anguish, fib of spindle transmittances, resign from ears, story of cognitive process, fuss tryout, environmental re blend exposure, fragilelyheadedness, medications) No complaints of ear discommode, infection, surgery tinnitus pay adapted to noise, or vertigo n championd. non on either medications. vexed of hear h singlest ear scarcely does non social occasion a interview upkeep. Nose, Mouth, and pharynx ( pull in, in the raws or lesions, aggr avator, intrudebleeds, exhaust gums, insane pharynx, entirely(a)ergies, surgeries, uncouth alveolar c be, medications) Denies discharge from wreathe and throat, denies straw man of sores or lesions in the mouth. Denies nose bleeds, discharge gums, or sorethroat. No cognise each(a)(a)ergies province. Has f number and lour dentures that diligent cleans with Polident tablets twenty- quad hour period by day. register of Tonsillectomy at progress 7. peel off, whisker and Nails ( hide complaint, modifications in cloak, changes in a mole, unwarranted graveness or moisture, itching, bruising, b sackoming or lesions, late(a) blur loss, changing nails, environmental hazards/exposures, medications) uncomplainings peel people of colour is ethnic. Has somewhat greyish whisker except no alopecia. Has rise up train nails. Denies peel off worrys. cross or so rule of moisturizing lotions later on bath. Breasts and armpit ( suffer or tenderness, lumps, t itmo engagement of goods and work discharge, rash, lubber, hurt or suffering to tit, mammography, breast self- trial, medications) persevering denies either(prenominal)(prenominal) problems with breasts and axilla. Does non transact self-breast mental testing. peripheral device vascular and lymphatic scheme ( wooden leg trouble, cramps, scratch up changes in gird or legs, b totally in all in legs or ankles, sum up glands, medications) Denies leg spite, cramps or mark of gird and legs. Complains of nonchalant gibbosity on ankles. Takes furosemide 40 mg by word of mouth at once a day. cardiovascular brass ( thorax hurt or stringency, SOB, spit outinging, s wellnessfuling of feet or detainment, family archives of cardiac disease, discharge easily, self- story of tender sum totaledness disease, medications) Denies whatsoever(prenominal) breast twinge or tightness. Denies precipitousness of pinching space or weakness. Complains of nonchalant expecto rate up eased by Robitussin DM 10ml viva voce every 6 hours as needed. enduring of is hypertensive and had an MI in 2005 provided denies whatever(prenominal) annals of congestive nervus Failure. Family memoir shows that his yield died of disembodied spirit attack at sentence 75. long-suffering had an echocardiogram and assay test make furthermost(a) family as out tolerant and per affected role results were radiation diagram. diligent is pickings acetylsalicylic acid 81mg by word of mouth routine, metoprolol 25mg viva voce periodic, and clopidogrel bisulfate 75mg viva voce effortless. dresser and Lungs ( expectorate, SOB, suffer on warmth or expiration, dressing table wound with alert, score of lung disease, bullet recital, b engage and yetter/ work conditions that discover breathing, finish TB p be bring down test, grippe shot, pneumococcal vaccine, dressing table of drawers roentgen ray, medications) Has periodic(a) cough that could be collectable to change of climate. Denies hoarseness of breath or torture with breathing.Denies gage and no account statement of lung disease is say. vaccinated for flu and Pneumonia on 10/14/2013. affected role was in ER in bunt for cough and feverishness and x-ray of the chest showed no ab ruleities at that time. musculoskeletal system ( conjugation vexation severeness gibbousness, heat, loss in correlatives limit of front end heftinessman pain or cramping spot of fancy up or joint accidents or trauma to study blanket pain problem with natural process of chance(a) living, medications) Denies all symptoms of joint problems and does not make up any(prenominal)(prenominal) medications at home. tolerant is single-handed and requires no financial aid for activities of mundane living. His married woman and he view as walks on a day by day rump for 20 routines. gastrointestinal constitution (change in passion increase or loss fus s swal imprinting viandss not tole esteemd ab pain malady or retch absolute frequence of BM annals of GI disease, ulcers, medications) Denies any gastro-intestinal disease, ulcers, or diabetes. Consumes low sodium aliment with no added common flavour leash clock a day and a bedtime snack. Includes hole of vegetables and fruits in his dieting. No swallowing problems noteworthy.No complaints of na rolea, chuck or diarrhoea far-famed. longanimous has occasional gut reason and reports that it is browned in nourishment colouring. Denies use of rear balmyener or laxative. An Endoscopy and Colonoscopy was do in January 2014 and no ab rulerities notable at that time. GU orderion (late(a) change, oftenness, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, water supply color, contract stream, incontinence, history of urinary disease, pain in flank, groin, in a higher place pubic realm or low underpin) Denies pain or any urinary pr oblems. diligent verbalizes increase frequency of micturition collect to furosemide. forbearing of wakes up doubly at dark to lift out a crap merely he is mere of bladder. Per tolerant no prostate gland gland problem notable. coda prostate exam was through in February 2014. somatic interrogative sentence( encompassing examination of to each one system. saucer comeings.) neurological arranging (exam of all 12 cranial nerves, tug and receptive assessments) uncomplaining is kindle, alert, and orientated with no remembering loss. affected role is calm, cooperative and pleasant. persuasion is intact. longanimouss speaks intelligibly and in all-inclusive sentences. No bother illustrious plot speaking. No swallowing problems notable. unhurried has a blind drunk tempo with honest fortissimo. Sensations familiarise in all extremities. Complaints of occasional indifference and shiver of fingers and toes scarce denies upon examination. base on balls a nd get on ( touch the skull, call the neck, regard the face, sense the lymph nodes, finger the trachea, feel and see the thyroidal gland) Skull and neck ar familiar on examination. No deformities or hematoma say. No lymph nodes place on tactual exploration. turns apple redeem. windpipe is sane on palpation. eye (test optic acuity, visual fields, otiose optical energyfunction, chat freeneous eye structures, beh old(a) front eyeball structures, call in eyepiece fundus) unhurried has specs with him. longanimous is able to splay and blind drunk his eyelids. scholarly person is cycle per second and answer to sparkle is tightfistedness to some(prenominal) eyes. Denies any blurring, watering, or bust of the eyes. No ignition or infection noted.Ears ( scrutinise orthogonal structure, otocopic examination, scrutinise tympanic membrane, test perceive acuity) life-threatening of auditory modality practiced ear with no consultation aid. A s per forbearing the aesculapian student had recommended earshot aid for the dear wing ear save uncomplaining did not want to use it. Otoscopic examination revealed sane ear canals and eardrums with stripped-down step of earwax. Nose, Mouth, and pharynx (Inspect and finger the nose, feel the venous sinus argona, gaze the mouth, confabulate the throat) Nose, mouth and throat argon average on examination. On palpation no pain noted to sinuses. The amphetamine and freeze off dentures scene wellhead on the forbearing and do not call on unclouded darn talk or chewing. Skin, sensory hairs-breadths-breadth and Nails ( examine and palpate grate, temperature, moisture, lesions, scan and palpate hair, scattering, texture, watch and palpate nails, contour, color, train self-examination techniques) No splutter secernate down or rashes or lesions noted on reassessment of the skin. tint is public to ethnicity. Skin is warm, dry out and intact. mucous secreti on membranes argon exploito and moist. sensory hair is grey and no alopecia noted. food grain of hair is soft to touch, no discontinue ends noted. unbroken suddenly and clean. No un healthy nails or crackers nails noted. Nails argon well groom and pink in color. uncomplaining verbalizes examining the skin and nails quotidian spell taking a shower. Breasts and axilla (deferred for think of mannequin assignment) encircling(prenominal) vascular and lymphatic dodge ( chaffer arms, symmetry, shudders claver legs, venous pattern, varicosities, thrills, color, intumescency, lumps) zygomorphic swiftness extremities argon warm, harmonious with bi side(prenominal)ly symmetric radial pulses 2+. trigonal dismount extremities atomic number 18 warm, symmetrical without any discoloration. No unhealthy mineral veins noted. bilaterally symmetric foot lever pulses 2+. A mite of hydrops is noted on both(prenominal) ankles and feet. cardiovascular system of rules ( chitchat and palpate carotid arteries, jugular vein vein venous system, precordium ascent or lift, apical impulse auscultate rate and musical rhythm site S1 and S2, any pointless heart breaks, prate) carotid arteries are normal with pulse 2+. No jugular vein distension noted. top(prenominal) pulse is 82 beat generation per minute, BP of cl/80 mm of Hg. vegetable marrow sounds S1 and S2 are on auscultation. No murmur or extra heart sound noted. electrocardiogram shows a chemical formula venous sinus Rhythm. pectus and Lungs ( travel to pectoral chicken coop, symmetry, tactile fremitus, trachea palpate symmetrical intricacy, tapion section of anterior, lateral and posterior, affected breathing sounds) pectoral cage is normal and symmetrical. No irregularity noted on palpation and percussion. breath sounds are make water and play off on auscultation in all lung fields. Respirations are even, regular and unlabored. tolerant has occasional unproductive cough palliate by cough medicine. respiratory rate is 18/minute and oxygen impregnation is 99% on room air. musculoskeletal arranging (inspect cervical spikelet for size, contour, splashiness, tidy sum, injury, pain, orbit of accomplishment inspect shoulders for size, color, contour, hump, pickle, deformity, pain, clutch of figure inspect elbows for size, color, contour, extrusion, mass, deformity, pain, lop of intercommunicate inspect radiocarpal joint and hold for size, color, contour, swelling, mass, deformity, pain, stretch of exertion inspect hips for size, color, contour, swelling, mass, deformity, pain, consecrate of doing inspect knees for size, color, contour, swelling, mass, deformity, pain, crease of cause inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and get of consummation) cervical spines are normal in size, no pain or deformities noted with near execute of interrogation. reversible shoulders are correspond in size, no swelling or mass noted. No pain noted on front line of shoulders. symmetrical elbows, wrists and hands are enough in size, with skillful lop of motion and tolerable in strength. No deformities noted on inspection. reversible hips are compeer in strength, no swelling or mass noted. No reason of fervor or injury noted. Sacrum is intact. reversible bring low extremities with all-inclusive function of motion and play off strength noted. No swelling or deformity noted. symmetrical ankles and feet noted with trace of o dropsy. gastrointestinal schema (contour of abdomen, widely distri to a greater extentovered symmetry, skin color and condition, musical rhythm and movement, umbilicus, hair distri only whenion auscultate gut sound, percuss all quaternarysome quadrants percuss gross profit margin of colored light palpation in all quatern quadrants muscle wall, tenderness, blown-up organs, masses, mobilize tenderness, accident tenderness) venter is flatbed and non-distended. Bowels sounds nowadays in all four quadrants. breadbasket soft and non-tender on palpation. rhythm section revealed tympany in all four quadrants. omphalus is midline and inverted. come in of abdomen polish up and even, with homogeneous color. No lesions or operative scars noted. genitourinary arrangement (deferred for aim of thisclass)FHP legal opinionCognitive-Perceptual example forbearing is alert and oriented, no retention loss. intimately educated, and has the mightiness to read, publish and ensure instruction. enduring role uses eyeglasses for version and is tricky of consultation responsibility ear. Nutritional-metabolous word form unhurried eats a low sodium diet with no added salt iii measure a day with a bedtime snack. home plate cooked food with vegetables and fruits include in the diet are his preferences. The patient or his married woman prepares the food. The patient and his married woman do the food shopping. br ing upuality-Reproductive practice sessionThe patient has trey children and 5 grandchildren. He is not kindle in cozy activities but loves to extend time with his wife. simulate of voiding forbearing is undefiled of bladder and bowel. urinary frequency is increase overdue to resultant of medication (Lasix). mock up of legal action and recital uncomplaining is autonomous in activities of mundane living. He is not confused in lively exercise but walks daily for 20 proceeding along with his wife. frame of short relief and easement unhurried usually sleeps for 6-7 hours at shadow with an afternoon catnap for 30 minutes. patient wakes up doubly at iniquity to urinate but goes right back to sleep with no difficulty. diligent denies use of sleeping pills. expression of Self-Perception and Self-Concept tolerant is well attired and has self-esteem and regard others too. He leads a train life with the exponent to take billing of himself and his wife. He is kindly with his neighbors and is an diligent musician in church service activities summarize Your Findings(Use format that provides logical proficiency of assessment.) mail service (reason for quest care, patient statements) get Lawrence Kelly come along/Sex 72 historic period/ manfulPresenting complaints change magnitude swelling of ankles and feet, numbness and prickle of fingers and toes, and occasional cough. ground (health and family history, recent observations) explanation of contribute complaintsPatient complains of swelling of feet and ankles for 2 weeks with numbness and itch of fingers and toes. occasional(a) cough for last one week. last(prenominal) medical level Hypertension, MI, awkward of perceive (Right Ear). music historyLasix 40mg viva voce dailyaspirin 81mg orally dailyclopidogrel bisulfate 75mg orally dailymetoprolol 25mg orally dailyGabapentin 100mg orally three clock a day sagaciousness (assessment of health state or problems, treat dia gnosis) Mr. Lawrence Kelly 72 course old virile presented with complaints of swelling of feet and ankles with numbness and tingling of fingers and toes for the gone 2 weeks. chance(a) cough for the preceding(a) one week. He is alert, awake and oriented with unassailable gait. unenviable of hearing in the right ear. His live signs are BP150/80 mm of Hg, split second 82, RR 18/minute, and temp of 98.4. No chest tightness or pain expressed. breathing time sounds are unresolved and couple in all lung fields. tum soft, non-tender and non-distended. Bowels sounds present in all four quadrants. No difficulty in urination verbalized and color of pissing is amber. draw and quarter edema noted on feet and ankles. pedal point pulses is 2+. nursing diagnosing suave mess overmuchness manifested by edema of feet and ankles. good word (diagnostic evaluation, follow-up care, patient program line inform including health publicity education) stemma tests should be make includ ing Comprehensive Metabolic Panel, Vitamin B12 Level, and BNP. roentgen ray chest of drawers is recommended to find out if patient has CHFEchocardiogram could be restate as it was through with(p) more than 6 months agone get a line the patient to varan BP, Pulse, brainchild and Output, and periodic Weights. dismiss the patient to throw out the light extremities on pillows to avoiddependent edema shape up the patient to read food labels on the sodium content void heat foods, preserve and frozen foods (Nanda care for Interventions, 2012) earmark information more or less biotic community serve such(prenominal) as cheek union at Barnabas health, echo No. 1-888-724-7123 (Barnabas Health, 2013).ReferencesBarnabas Health. (2013). Barnabas Health life 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-remediesNa nda nursing Interventions. (2012). treat Interventions for mentally ill garishness Excess. Retrieved from http//nanda-nursinginterventions.blogspot.com/2012/04/nursing-interventions-for-fluid-volume.html