Health history examination of a freelance journalist with computer-related symptoms

Health History Examination

FUNDAMENTAL IN ADULT CARE

Individual Client Health History Examination of an Older Adult

Client/Patient Initials LNP Sex: F. Age

Occupation: free-lance researcher- journalist

Health History/Review of Systems

Neurological System -- the patient seldom suffers headaches or dizziness. She has no difficulty speaking or swallowing. She only takes vitamin and mineral supplements on a daily basis. She sits long hours before a computer because of her work, however. And thus experiences numbness in the legs and feet.

Head and Neck -- except for stiff neck due to computer work, she does not suffer from any significant causes in this area.

the patient is highly myopic and occasionally experiences visual migraine. She wears contact lenses but no medications.

Ears -- Nothing abnormal or disturbing about her hearing

Nose, Mouth and Throat -- no disturbing nose, mouth or throat discharges except for 3 defective teeth that need root canal therapy.

Skin, hair and nails -- no color changes, dryness, bruising, hair loss, nail problems. Patient's skin is clean and soft.

Breasts and axilla -- no tenderness, no lumps or discharges, swelling or injury.

Peripheral, vascular and lymphatic system -- leg pains and cramps but no swelling. Leg pains are relieved by stretching from ergonomic work.

Cardiovascular system -- no chest pain or tightness, no coughs or swelling of the hands or feet. She does not tire easily but walks fast for hours with very little fatigue. She does not take any heart medications.

Thorax and Lungs -- no coughs or painful breathing and no history of lung disease although she smoked for 10 years and then stopped. No flu or TB shots.

Musculoskeletal system -- joint stiffness and muscle pains most of the day because of daily and intense computer work.

Gastrointestinal System -- no appetite problem or difficulty swallowing. Food is well tolerated. She seldom suffers from loose bowel movement or constipation or ulcers. She has been eating brown rice and whole wheat products for 3-4 years now.

Genitourinary system -- no abnormal discharges or pain except for pain in sitting down for long hours before the computer for online work.

Physical Examination

Neurological System -- no abnormalities in any of the 12 cranial nerves. Motor and sensory reflexes are normal and strong.

Head and Neck -- no abnormalities, no lumps or cuts on the face, lymph nodes, the trachea or thyroid glands.

Eyes -- visual migraine occasionally occurs, often after long hours of computer work and exposure to bright light of the monitor. High myopia is corrected by contact lenses.

Visual fields are normal.

Ears -- normal external structure. Hearing normal and strong. Tympanic membrane intact.

Nose, Mouth and Throat -- nasal irritation and occasional discharges because of patient's allergic reaction to dust. She wears partial removable dentures to compensate for missing teeth. No visible throat abnormalities. Tissues look normal in form and color.

Skin, Hair and Nails -- Patient's skin is clear, clean and youthful-looking despite her age. Her skin is almost flawless and well-moisturized. Hair is glossy, soft and clean with increasing grays. Nails are healthy and pink.

Peripheral vascular and lymphatic system -- Arms and legs are symmetrical and normal looking and functioning. There are no swellings or varicosities. Her skin texture throughout is fine and smooth. The patient has been taught self-examination techniques and she uses them on herself.

Cardiovascular system -- carotid arteries appear slightly inflamed probably because of long hours of computer work. Heart rate seems fast. Blood pressure is 120/80. There are no abnormal heart sounds or murmurs.

Thorax and lungs -- thoracic cage, trachea and other parts in this system are normal looking and functional. There are no abnormal breathing sounds.

Musculoskeletal system -- The patient has no swelling or masses, deformities in any of the parts in this system. Her extremities are painful from continued computer work but are otherwise normal functioning. The patient sees a physical therapist or chiropractor to correct defects in these parts.

Gastrointestinal system -- the patient has normal or ideal symmetry. The abdomen is slightly distended and she says she has gained a few pounds in the last months. Her skin color is normal and pinkish. Hair distribution is normal. No bowel movement abnormalities in the last years except a few times. No muscle tenderness or masses or enlargements in any organ in this system.

Summary of Findings

Situation -- the patient seeks care for visual migraine, muscle cramps, tooth abscesses, and allergic reaction. She says she has panic attacks at times when walking in tall footpaths.

Her father died from head trauma at age 99. Her paternal grandfather died from a heart condition at age 93. Her mother died at 59 from color cancer. Her high-cholesterol level due to an uncontrolled fatty diet but this has been eliminated.

Assessment of health state, problems or diagnosis -- The patient develops allergic reactions to dust and severe and sustained headaches for days. She cannot fall asleep except at around 4 or 5AM and wakes up at around 10 AM but refreshed. When she has no outside activity, she sleeps every less. Her muscle cramps and leg soreness are associated with long hours of computer work. She also has at least 3 defective, aching teeth, which require prompt attention.

Recommendation -- the patient should consult a sleep disorder expert to improve her sleep pattern. She needs to undergo root canal therapy for her teeth. She also needs to seek medical help for her allergy to dust. She likewise needs to restructure her work hours and ergonomic paraphernalia to reduce muscle cramps and tingling.