Health History and Examination
Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems
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Student Name: | Date: |
Client/Patient Initials: | Sex: | Age: |
Occupation of Client/Patient: |
Health History/Review of Systems(Complete and systematic review of systems) |
Neurological System (headaches, ...view middle of the document...
No lenses were implanted. Per patient “I go and see my eye doctor in timely manner” Patient is far sighted wears Glasses. On assessment PERRLA is sluggish in both eyes. |
Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications):No recent change in the hearing was reported. No history of Tinnitus, vertigo or ear trauma was reported. Tympanic membrane in intact, No wax was present. Whisper test positive. Patient uses Cotton swabs to clean the ears. |
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications):No frequent throat infection was reported. Per patient sometime gets seasonal allergies, Patient is on Zyrtec 1 Tablet PRN. No family History of Mouth or throat cancer was reported. Patient has upper and lower dentures in placed. No hoarseness or changes in the voice was reported. Uvula in midline. No dysphagia was reported. Nose is midline, No deviation or perforated septum was observed. Smelling sense is intact. Gag reflex present. |
Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications):Skin is pink, warm, dry and Intact. Skin turgor is poor due to aging. No skin breakdown was noted. Old appendectomy scar in present on the RLQ. Almost 5 inches long, white in color. Hair is grey. Per patient uses hair color as needed. Normal distribution of hair. Nail are smooth No Clubbing was observed. Capillary refill in <3 Sec. No Alopecia was reported. Patient uses Lotion to keep skin moist. Instructed on skin breakdown prevention. |
Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications):Breasts are Bilateral moderate in size and symmetrical. Skin is pale and pink. Areolas are light brown, Nipples everted bilaterally. No dimpling, retraction or lesion was noted. No rashes were observed. No masses or tenderness was noted on palpation. Per patient Mammogram was done last year, can’t recall the date. Per patient Results were normal. Patient was educated on Self breast examination and was reinforced on performing it. |
Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications):Patient has history of arthritis. Takes Tylenol 500 mg PO 1-2 tablets as needed. Patient develops dependent edema for prolong sitting position. No swollen lymph nodes were noted. No swelling, Pinkish skin tone. No clubbing of finger tips, Warm Bilaterally. |
Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart...