Health History Examination Fundamental in Adult Care

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.

FHP Assessment

Cognitive-Perceptual Pattern -- the patient is largely informed and conscious about health maintenance. She walks 3 hours around the block per week. She complains chiefly of allergic reaction to dust, which she manages to prevent by keeping herself and her surroundings as clean as possible. Her other chief problem is an abnormal circadian rhythm, which makes her sleep at irregular intervals and for only a few hours in the last few months.

Nutritional Metabolic Pattern -- the patient is largely well-nourished: her regular intake corresponds to recommended amounts. She puts her learning about health into actual use in her lifestyle and diet. Her diet is quite fibrous and with minimal fats and sugars.

Sexuality-Reproductive Pattern- the patient is single, lives alone and celibate. She finds fulfillment and freedom in that.

Pattern of Elimination -- her fibrous diet prevents problems in elimination. She evacuates 2-3 times a day without fail. Her stools are always normal.

Pattern of Activity and Exercise -- She balances her long hours of computer work and sitting down with alternate days of walking fast and long distances around her residence. She walks from one end of the street to the other and then ends by buying groceries. She climbs 3 sets of stairs each time as there are no elevators or escalators in her residence building. This routine complements her every-other-day walks to the grocery.

Pattern of Sleep and Rest -- Although she suffered from delayed phase sleep disorder a few months ago, she has to some extent overcome it. The time she actually falls asleep has not been consistently regulated, but she falls asleep and sleeps restfully in the last many weeks after eliminating her prescribed prescription for midazolam.

Pattern of Self-Perception and Self-Concept -- The patient likes to look at herself because she looks much younger than 66. Everyone also tells her so. Her older family members slow-agers like herself. This is her self-perception despite stereotype perceptions about aging (Besdine, 2009; Debacker, 1999; Wiggins & Swagerty, 2008; Christ, 2012). She is quite functional and enjoys both work and relationships at high levels.