Health Assessment I
Patient Identification:
• Initials: HD
• Age: 30
• DOB: January 30th, 1986
• Race: Middle eastern
• Sex: Female
• Religion: Patient practices the religion of Islam.
• Occupation: Patient is currently in medical school.
Past Medical History
• Illnesses: Patient denied any present or past illnesses.
• Surgeries/Procedures: Patient stated they had left foot surgery in 2007
• Childhood Illnesses: Patient stated they Chicken Pox at the age of 5.
• Trauma: Patient denied any trauma.
• Most Recent Physical Examination: Patient stated their last physical was May 2016.
• LMP: Patient stated her last PMS was recent on August 5,2016. She stated it lasted about seven days.
Medications
• Prescription: Patient stated they aren’t taking any prescribed medications.
• OTC: Patient stated they take Vitamin D tablets 1000 I.U. twice daily for bone strength.
Allergies
• Medication, Food and Environmental: Patient denies any known allergies
Social History
• Tobacco: Patient denies any tobacco use.
• Alcohol: Patient denies any alcohol use.
• Caffeine: Patient denies caffeine use.
• Recreational: Patient denies any recreational use.
• Drug Use: Patient denied any current or past drug use.
• Immunizations: Patient received Influenza, Tdap booster, Varicella, Measles, mumps, rubella (MMR), Hepatitis B, Hepatitis A over her lifetime.
• Travel: Patient travelled to Canada in March 2016, and travels out of state to Chicago every two weeks.
Family History
• Marital Status: Patient states they’re single.
• Parents: Patient stated their parents are still alive and she currently lives with them.
• Family illnesses: Patient stated that their mother has breast cancer, and their grandmother had ovarian cancer which then lead to her death from stage 4 cancer. Her mother has glaucoma also.
Review of Systems: (this is told by the patient during the interview)
• General: Patient stated they’re within their normal weight. Patient denies any Weakness, fatigue, or fever.
• Head, Ears, Eyes, Nose, Throat;
Head: Patient states they began having frequent Headaches for about two weeks. Patient denies any injury, dizziness, or lightheadedness. Eyes: Patient states she has 20/30 vision; patient denies needing any glasses or contact lenses. Patient denied any pain, redness, double or blurred vision, glaucoma, cataracts. She stated her last examination was in June 2016. Ears: Patient denies having any Hearing problems, tinnitus, vertigo, earaches, infection, discharge. Nose and sinuses: Patient stated they rarely gets sick; Patient denies nasal stuffiness, discharge, itching nosebleeds and sinus trouble. Throat: Patient denies any bleeding gums decreased taste sensations, dry mouth, or frequent sore throats.
• Gastrointestinal: Patient denies any Trouble swallowing, heartburn, or nausea. Patient states they have daily Bowel movements, stool color is usually brown and medium sized, she denies any change in bowel habits, or pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Patient denied any Abdominal pain. Jaundice, liver, or gallbladder trouble.
• Pulmonary: Patient denies shortness of breath, or cough.
• Cardiac: Patient denied any Heart trouble, high blood pressure, chest pain or discomfort.
• Genitourinary: Patient denies incontinence, hematuria, dysuria, or urinary infrequency
• Musculoskeletal: No changes in strengths, no joint tenderness or swelling.
• Vascular: No leg cramps, varicose veins, past clots in the veins; swelling in calves, legs, or feet. No swelling, redness or tenderness.
• Endocrine: No changes in appetite. Denies cold intolerance, heat intolerance, polydipsia, polyphagia, polyuria.
• Blood: Patient denies any clots or excessive bleeding.
• Integumentary: Patient denies itching, pain, rashes, or blisters. Patient denies any roughness, bumpy, or puffy skin.
• Psychological: She denies having depression, anxiety, memory loss, mental disturbance, suicidal ideation, hallucinations, or paranoia.
Physical Examination:
General Appearance:
VS: Temperature: 98.6F (oral)
Pulse: 90, regular
Respiratory Rate: 12
Blood Pressure: 120/82
Oxygen Saturation: 98%
Pain Score: 0/10
HEENT:
Head, Eyes, Ears, Nose, Throat (HEENT). Head: Hair evenly distributed. Scalp without lesions. Conjunctivae and lids normal, pupils equal, round, reactive to light and, accommodation(PERRLA), discs sharp and flat, No hemorrhages, or exudates, normal visual acuity, EOM intact. External ears normal, no lesions or deformities; external nose normal, no lesions or deformities; canals clear bilaterally, tympanic membranes intact with good movement, no fluid; hearing grossly intact bilaterally; nasal mucosa, septum, and turbinate’s normal; intact healthy pink gums and teeth, tongue normal, posterior pharynx without erythema.
Neck: Neck is supple, no masses, trachea midline; no thyroid nodules, masses, tenderness, or enlargement.
Lymph Nodes: Small, soft, non-tender, and posterior cervical nodes bilaterally. Several tiny inguinal nodes bilaterally, soft and non-tender. Non-palpable, no abnormal findings.
Breast: Tender, symmetrical. No visible or palpable masses; nipples with no discharge.
Respiratory/Thorax: Thorax is symmetrical with good excursion. Lungs display a resonance sound. Breath sounds vesicular with no added sounds. Diaphragms descend bilaterally.
Cardiac: No Jugular venous distention. Carotid arteries without bruits. Apical impulse barely palpable in the 5th left interspace. S1, S2; no S3/S4. No murmurs.
Abdomen: Protuberant. No scars or lesions. Bowel sounds active. No tenderness or masses. Liver span 7 cm in right mid-clavicular line; edge smooth, palpable below right costal margin. No costovertebral angle tenderness. Spleen and kidneys not felt.
GU: Exam deferred
Rectal: Exam deferred
Vascular/Pulse: No edema present. No varicosities veins on lower extremities. No pigmentation or ulcers. Pulses (2 + brisk/normal)
Musculoskeletal: No joint deformities found. Good range of motion in hands, wrists, elbows, shoulders, knees, ankles, spine, or hips.
Neurological (including cranial nerves I-XII, Motor, Coordination, Sensory, Reflexes): Mental Status: Alert and cooperative, thought coherent. Oriented x4 to person, place, and time. Cranial Nerves: II–XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout all regions Cerebellar: RAMs, point to point movements intact. Gait normal, no fluid. Sensory: Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative. Reflexes: Normal.
Reflection
I used my friend’s older sister, I brought all my nursing equipment to their home and started my physical on her. I went to their house in the afternoon and stayed for about an hour just to get an in-depth assessment. I haven’t known her for long time so it felt odd asking her questions that she might deem personal. This was good practice because I will be doing this in the hospital with most if not all my patients. I faced some barriers as she wasn’t fluent in English and I’m not as fluent in Arabic or at least the in dialect she spoke. I do wish I went more in depth with her family history being as if cancer runs in her family then other people within her family must have it. Which I recommended she get checked for the Brca gene, which she then told me she doesn’t have insurance which means she doesn’t go to the doctor as often as she should. She also refused the GU and rectal exam because she didn’t feel comfortable uncovering herself in front of anyone. She told me because she is single and a virgin she never saw the need to visit a gynecologist. I tried my best to use eye contact, understanding, and facing her while I spoke to her. But each time she would start looking down and would become nervous. I’m glad I took my time with her assessment because I was able to make it to where she wasn’t as nervous as she was in the beginning. Next time I would try and open up, be more interactive and make them feel comfortable before we start the assessment. This experience was very eye opening for me.