Health History and Examination
Health History and Examination
Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications): Patient is alert, awake and oriented. Denies headaches, head injuries, dizziness, seizures, tremors, migraine, difficulty in speech and swallowing. No history of falls. Patient does mention that he has numbness and tingling of fingers and toes occasionally. Takes Gabapentin 100mg orally three times a day. Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Patient denies neck or head injuries, denies swelling or lumps on neck and head, Denies neck pain or headaches. Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications): Patient wears eyeglasses that are with him. Bilateral cataract surgery done in June 2013. Regular vision checks after surgery done in November 2013 and at present he is not on any medications at home. Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): No complaints of ear pain, infection, surgery tinnitus due to noise, or vertigo noted. Not on any medications.
Hard of hearing right ear but does not use a hearing aid. Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): Denies discharge from nose and throat, denies presence of sores or lesions in the mouth. Denies nose bleeds, bleeding gums, or sore throat. No known allergies noted. Has upper and lower dentures that patient cleans with Polident tablets daily. History of Tonsillectomy at age 7. 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): Patient’s skin color is ethnic. Has some gray hair but no alopecia. Has well groomed nails. Denies skin problems. Particular about usage of moisturizing lotions after bath. Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications): Patient denies any problems with breasts and axilla. Does not perform self-breast examination.
Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications): Denies leg pain, cramps or discoloration of arms and legs. Complains of occasional swelling on ankles. Takes Lasix 40 mg orally once a day. Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications): Denies any chest pain or tightness. Denies shortness of breath or weakness. Complains of occasional cough relieved by Robitussin DM 10ml orally every 6 hours as needed. Patient is hypertensive and had an MI in 2005 but denies any history of Congestive Heart Failure. Family history shows that his father died of heart attack at age 75. Patient had an echocardiogram and stress test done last year as outpatient and per patient results were normal. Patient is taking Aspirin 81mg orally daily, Lopressor 25mg orally daily, and Plavix 75mg orally daily. Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications): Has occasional cough that could be due to change of climate. Denies shortness of breath or pain with breathing.
Denies smoking and no history of lung disease is noted. Immunized for Influenza and Pneumonia on 10/14/2013. Patient was in ER in March for cough and fever and x-ray of the chest showed no abnormalities at that time. Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications) Denies any symptoms of joint problems and does not take any medications at home. Patient is independent and requires no assistance for activities of daily living. His wife and he take walks on a daily basis for 20 minutes. Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications) Denies any gastro-intestinal disease, ulcers, or diabetes. Consumes low sodium diet with no added salt three times a day and a bedtime snack. Includes plenty of vegetables and fruits in his diet. No swallowing problems noted.
No complaints of nausea, vomiting or diarrhea noted. Patient has daily bowel movement and reports that it is brown in color. Denies use of stool softener or laxative. An Endoscopy and Colonoscopy was done in January 2014 and no abnormalities noted at that time. Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, supra pubic region or low back) Denies pain or any urinary problems. Patient verbalizes increased frequency of urination due to Lasix. Patient wakes up twice at night to urinate but he is continent of bladder. Per patient no prostate problem noted. Last prostate exam was done in February 2014. Physical Examination
(Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments): Patient is awake, alert, and oriented with no memory loss. Patient is calm, cooperative and pleasant. Judgment is intact. Patients speaks clearly and in full sentences. No difficulty noted while speaking. No swallowing problems noted. Patient has a steady gait with full strength. Sensations present in all extremities. Complaints of occasional numbness and tingling of fingers and toes but denies upon examination. Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland): Skull and neck are normal on examination. No deformities or hematoma noted. No lymph nodes identified on palpation. Adam’s apple present. Trachea is normal on palpation. Eyes (test visual acuity, visual fields, extra ocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus): Patient has eyeglasses with him. Patient is able to open and close his eyelids. Pupil is round and reaction to light is constriction to both eyes. Denies any blurring, watering, or tearing of the eyes. No redness or infection noted.
Ears (inspect external structure, otocopic examination, inspect tympanic membrane, test hearing acuity): Hard of hearing right ear with no hearing aid. As per patient the physician had recommended hearing aid for the right ear but patient did not wish to use it. Otoscopic examination revealed normal ear canals and eardrums with minimal amount of earwax. Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat): Nose, mouth and throat are normal on examination. On palpation no pain noted to sinuses. The upper and lower dentures fit well on the patient and do not become loose while talking or chewing. Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach self-examination techniques): No skin break down or rashes or lesions noted on inspection of the skin. Color is normal to ethnicity. Skin is warm, dry and intact. Mucus membranes are pink and moist. Hair is gray and no alopecia noted. Texture of hair is soft to touch, no split ends noted.
Kept short and clean. No ingrown nails or cracked nails noted. Nails are well groomed and pink in color. Patient verbalizes examining the skin and nails everyday while taking a shower. Breasts and Axilla (deferred for purpose of class assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps): Bilateral upper extremities are warm, symmetrical with bilateral radial pulses 2+. Bilateral lower extremities are warm, symmetrical without any discoloration. No varicose veins noted. Bilateral pedal pulses 2+. A trace of edema is noted on both ankles and feet. Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S1 and S2, any extra heart sounds, murmur): Carotid arteries are normal with pulse 2+. No jugular vein distension noted. Apical pulse is 82 beats per minute, BP of 150/80 mm of Hg. Heart sounds S1 and S2 are on auscultation. No murmur or extra heart sound noted. EKG shows a Normal Sinus Rhythm.
Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds): Thoracic cage is normal and symmetrical. No abnormality noted on palpation and percussion. Breath sounds are clear and equal on auscultation in all lung fields. Respirations are even, regular and unlabored. Patient has occasional nonproductive cough relieved by cough medicine. Respiratory rate is 18/minute and Oxygen saturation is 99% on room air. Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and range of motion): Cervical spines are normal in size, no pain or deformities noted with full range of motion.
Bilateral shoulders are equal in size, no swelling or mass noted. No pain noted on movement of shoulders. Bilateral elbows, wrists and hands are equal in size, with full range of motion and equal in strength. No deformities noted on inspection. Bilateral hips are equal in strength, no swelling or mass noted. No evidence of redness or injury noted. Sacrum is intact. Bilateral lower extremities with full range of motion and equal strength noted. No swelling or deformity noted. Bilateral ankles and feet noted with trace of edema. Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness): Abdomen is flat and non-distended. Bowels sounds present in all four quadrants. Abdomen soft and non-tender on palpation. Percussion revealed tympany in all four quadrants. Umbilicus is midline and inverted. Surface of abdomen smooth and even, with homogenous color. No lesions or surgical scars noted. Genitourinary System (deferred for purpose of this class)
Patient is alert and oriented, no memory loss. Well educated, and has the ability to read, write and understand information. Patient uses eyeglasses for reading and is hard of hearing right ear. Nutritional-Metabolic Pattern:
Patient eats a low sodium diet with no added salt three times a day with a bedtime snack. Home cooked food with vegetables and fruits included in the diet are his preferences. The patient or his wife prepares the food. The patient and his wife do the food shopping. Sexuality-Reproductive Pattern:
The patient has three children and 5 grandchildren. He is not interested in sexual activities but loves to spend time with his wife. Pattern of Elimination
Patient is continent of bladder and bowel. Urinary frequency is increased due to effect of medication (Lasix). Pattern of Activity and Exercise:
Patient is independent in activities of daily living. He is not involved in vigorous exercise but walks daily for 20 minutes along with his wife. Pattern of Sleep and Rest:
Patient usually sleeps for 6-7 hours at night with an afternoon nap for 30 minutes. Patient wakes up twice at night to urinate but goes right back to sleep with no difficulty. Patient denies use of sleeping pills. Pattern of Self-Perception and Self-Concept:
Patient is well dressed and has self-respect and respects others too. He leads a disciplined life with the ability to take care of himself and his wife. He is friendly with his neighbors and is an active participant in church activities Summarize Your Findings
(Use format that provides logical progression of assessment.) Situation (reason for seeking care, patient statements):
Name: Lawrence Kelly
Age/Sex: 72 years/Male
Presenting complaints: Increased swelling of ankles and feet, numbness and tingling of fingers and toes, and occasional cough. Background (health and family history, recent observations): History of present complaints:
Patient complains of swelling of feet and ankles for 2 weeks with numbness and tingling of fingers and toes. Occasional cough for last one week. Past medical History: Hypertension, MI, Hard of hearing (Right Ear). Medication history:
Lasix 40mg orally daily
Aspirin 81mg orally daily
Plavix 75mg orally daily
Lopressor 25mg orally daily
Gabapentin 100mg orally three times a day
Assessment (assessment of health state or problems, nursing diagnosis): Mr. Lawrence Kelly 72 year old male presented with complaints of swelling of feet and ankles with numbness and tingling of fingers and toes for the past 2 weeks. Occasional cough for the past one week. He is alert, awake and oriented with steady gait. Hard of hearing in the right ear. His vital signs are BP150/80 mm of Hg, Pulse 82, RR 18/minute, and Temp of 98.4. No chest tightness or pain verbalized. Breath sounds are clear and equal in all lung fields. Abdomen soft, non-tender and non-distended. Bowels sounds present in all four quadrants. No difficulty in urination verbalized and color of urine is amber. Trace edema noted on feet and ankles. Pedal pulses is 2+. Nursing Diagnosis:
Fluid Volume Excess manifested by edema of feet and ankles.
Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education): Blood tests should be done including Comprehensive Metabolic Panel, Vitamin B12 Level, and BNP. X-ray Chest is recommended to find out if patient has CHF
Echocardiogram could be repeated as it was done more than 6 months ago Teach the patient to monitor BP, Pulse, Intake and Output, and Daily Weights. Advise the patient to elevate the lower extremities on pillows to reduce dependent edema Encourage the patient to read food labels on the sodium content Avoid fried foods, canned and frozen foods (Nanda Nursing Interventions, 2012) Provide information about community services such as Heart Center at Barnabas Health, Phone No. 1-888-724-7123 (Barnabas Health, 2013).
Barnabas Health. (2013). Barnabas Health Heart 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-remediesNanda Nursing Interventions. (2012). Nursing Interventions for Fluid Volume Excess. Retrieved from http://nanda-nursinginterventions.blogspot.com/2012/04/nursing-interventions-for-fluid-volume.html