Comprehensive Health Assessment Paper

Childhood illnesses include measles, mumps, rubella, and chickenpox. She has fallen many times however, has never broken any bones. Serious traumas include three concussions. Has had many surgeries including tonsils removed, gastric bypass, right hip replacement, 2 bilateral knee surgeries, cataracts removed, back surgery and is waiting for shoulders to be replaced. Reports sinus infections in the spring and fall due to pollen and mold. These symptoms are similar to the ones she is experiencing now. Several years ago, she traveled around the world for 7 months and was in England for the Mad Cow Disease outbreak.

At present, no diagnosis has been determined and past diagnoses were ruled out for not accounting for her various symptoms.

ENT: No abnormalities of the external auditory canals moderate cerumen. Pearly gray tympanic membranes on right ear with visible landmarks, while left ear shows bulging, slightly red (dark pink) tympanic membrane and No visible inner ear landmark . No signs of imperforation in both ears. Patent nares, moist, pink nasal mucosa. Lips, gums, and palate reveal no abnormalities or signs jaundice. No signs of dehydration of oral mucosa, gingivitis or lip edema.

Hypercholesterolemia, especially in light of her diabetes. She has lost weight and is making change in her lifestyle, which I congratulated her on. She is willing to start a statin medication at this point and will start Lipitor 10 mg one p.o. nightly. I did review liver implications of this and will recheck a lipid panel as well as CMP in three months time. We will also recheck a hemoglobin A1C at the same time. Also reviewed to avoid grapefruit juice to excess. She knows to call if she gets excessive muscle aches, etc.

After reading this patient’s history and physical, identify her signs and symptoms consistent with her

At today’s visit she is accompanied by her daughter. She is awake and alert. She reports numbness, tingling and itchy feeling inside of bilateral lower legs. She reports that it is constant and there are no relieving factors. She complains of dull pain in her shoulder which she rates as 4/10 in severity. Her shoulder pain does not radiate, moving her arms makes her pain worse. She suffers from chronic depression for which she takes antidepressant. She suffers from chronic anxiety which is managed with Xanax. The daughter reports that the patient has a poor appetite and has loss 4 lb. the patient

This is 38 year old Female. Patient reports chronic back pain. Dull aching pain, taht radiates down to her legs. Patient denies chest pain, SOB, N/V/D, or fever. Patient reports deressive moods, denies thoughts of sucide or homicide. Patient reports intermitten hadache, and she's been taking BC powder OCT.

In the analysis of the muscle, joints, nerves and blood vessels she has occasional pain but not severe complaints.

Head was inspected for size, shape, position and symmetry. Scalp noted clean and well maintain, no dryness, or lesions were noted. No sign of hair loss were observed. Facial structure were symmetrical, no skin discoloration, rashes, swollen or lesion were noted. No involuntary movement of the face were perceived. Neck was inspected, good symmetry were noticed, and no scar or lesions were perceived. No large lymph nodes or mass detected during palpation, patient denies pain or tenderness. Thyroid gland was not visible, during palpation no mass or nodule were identified. No bruit was perceived during auscultation of the thyroid lobes. Trachea was noted to be in the midline, no deviation was noted.

This is 40 year old WF. Patient has a history of HTN (currently not taking any medication), hypothyroidism (levothyroxin 1.12 mcg QD), and seasonal all just released for seasonal allergy (zyrtec 10 mg QD). Patient states she had all the labs prior to release from the prison system Patient denies chest pain, SOB, N/V/D, or fever. Patient reports some sinus congestion wit sinus headache, intermittent cough, denies fever. Patient is a formal tobacco user, denies use of tobacco, alcohol or illit drugs. Patient denies depressive

At today's visit, she is accompanied by her daughter. She is awake, alert and oriented. She reports chronic pain in her joints and generalized pain, which she describes as a “sore feeling” with a severity of 4/10. She states that her pain does not radiate but her pain is all over. She states that her pain is worse when she attempts to change positions. However she reports that her pain has much improved since starting the oxycodone 5 mg. she states that she takes a whole

“Ms. Hood has been diagnosed with hypertension, angina, Congestive Heart Failure (CHF), kidney disease and Parkinson’s disease. She has arthritis and chronic back problems.

A review of the medical records indicates that she suffers from multiple medical illnesses which include, advanced dementia, ADFT with 6 lb weight loss since March-BMI 16, chronic stable hypothyroid, chronic stable hyperlipidemia, chronic anxiety and chronic depression.

At today’s visit, she is accompanied by her caregiver from She is awake, alert and oriented. The patient report that her pain at this time is 0/10 in severity, however she reports that when she does not take her Percocet she has chronic, intermittent, dull, achy abdominal pain. The patient is calm and cooperative, no anxiety noted, however the caregiver reports that the patient has daily anxiety, times varies, some days her anxiety is worse than other. No acute distress noted. The patient reports a fair appetite. The care giver educated on what to do in the event that the patient’s AAA

Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that