Health History and Physical Assessment

Everything in blue is the instructions for you to continue writing the Health Education Needs and the Reflection of this assessment. (I haven’t done anything with these 2 parts yet.)

In addition, please help correct my gramma, proper spelling, and the use of APA 6th edition formatting, as well as how clearly the thoughts and reasoning are expressed in my writing style.

Running head: HEALTH HISTORY AND PHYSICAL ASSESSMENT 1

HEALTH HISTORY AND PHYSICAL ASSESSMENT 6

Health History and Physical Assessment

Student Name

Chamberlain College of Nursing

NR 304: Health Assessment II

August 2019

Health History and Physical Assessment

The person whose health was assessed will be referred to as AG throughout the paper.

Demographic Data

AG is a 41-year-old African-American female student at Chamberlain University College of Nursing. She is married and has three children, among ages six, four, and two.

Reason for Seeking Care

AG came into the office for routine annual check-up.

Present Illness

Her blood pressure is 132/70 and considered as the stage of pre-hypertension. Being an African-American adult, she is at risk of developing hypertension (Jarvis, 2015, p.137). A.G. confirms that her blood pressure is a little bit high, but she denies any pain and concern at this time. The main need of her is to educate her on further prevention hypertension and signs and symptoms of further complications.

Perception of Health

The client perceived, “I consider myself as a healthy person although my blood pressure slightly high, and I am currently in a good health.” She added that “daily exercise helps enhance an individual’s health.” Therefore, she engages in regular mild exercise every day such as climbing home stairs, doing house chores, and taking care of her three children. Furthermore, she avoids consumption of alcohol and tobacco usage. Finally, she limits her caffeine intake to one cup of coffee or one cup of tea per day to avoid addiction. Nevertheless, she identifies medium intake of fat and frequent breakfast skipping.

Past Medical History

AG denies any childhood illness, injury, or accident. She states she does not have any signs of allergies or chronic disease. She has been taking birth control pills for one year without other prescriptions or over-the-counter medications in current. The last time she sought health care services was on 10th January 2019. She mainly visited it for physical assessment. She has not suffered from any mental condition throughout her lifetime. The only reason she has been hospitalized 3 times is to give births to her 3 children; they are all healthy as well. Nonetheless, all of her immunizations are up-to-date; she has been immunized against MMR (measles, mumps, rubella), tetanus, hepatitis, influenza, chickenpox, pneumonia, and no TB screen test.

Family Medical History

Most of her family members have been diagnosed with no significant health problems, and their lifespans ranged from 75 to 90 years old except her mother who died of falling at the age 75; according to the text book, older adults increase risk of falling (Jarvis, 2015, p. 616). However, her father and other three sisters have not been diagnosed with any critical condition.

Review of Systems

General Health. Reports usual health “OK.” No recent weight change; no fatigue, weakness, fever, sweats.

Skin. No change in skin color, pigmentation, or nevi. No pruritus, rash, lesions. No history of skin disease.

Hair: No loss, change in texture.

Nails: no change.

Self-care: Stays in sun “as much as I can.” No use of sunscreen. Goes to tanning beds at hair salon twice/week during winter.

Head. No unusually frequent or severe headaches; no head injury, dizziness, syncope, or vertigo.

Eyes. No difficulty with vision or double vision. No eye pain, inflammation, discharge, lesions. No history of glaucoma or cataracts. Wears no corrective lenses.

Ears. No hearing loss or difficulty. No earaches; no infections now or as child; no discharge, tinnitus, or vertigo.

Self-care: No exposure to environmental noise; cleans ears with washcloth.

Nose. No discharge; has 2 or 3 colds per year; no sinus pain, nasal obstruction, epistaxis, or allergy.

Mouth and Throat. No mouth pain, bleeding gums, toothache, sores or lesions in mouth, dysphagia, hoarseness, or sore throat. Has tonsils.

Self-care: Brushes teeth twice/day, no flossing.

Neck. No pain, limitation of motion, lumps, or swollen glands.

Breasts. No pain, lump, nipple discharge, rash, swelling, or trauma. No history of breast disease in self, mother, or sister. No surgery.

Self-care: Does not do breast self-examination.

Respiratory. No history of lung disease; no chest pain with breathing; no wheezing or shortness of breath. Colds sometimes “go to my chest”; treats with over-the-counter cough medicine and aspirin. Occasional early-morning cough, nonproductive. Works in well ventilated tavern.

Cardiovascular. No chest pain, palpitation, cyanosis, fatigue, dyspnea with exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema. No history of heart murmur, hypertension, coronary artery disease, or anemia.

Peripheral Vascular. No pain, numbness or tingling, or swelling in legs. No coldness, discoloration, varicose veins, infections, or ulcers. Legs are equal in length.

Gastrointestinal. Appetite good with no recent change. No food intolerance, heartburn, indigestion, pain in abdomen, nausea, or vomiting. No history of ulcers, liver or gallbladder disease, jaundice, appendicitis, or colitis. Bowel movement 1/day, soft, brown; no rectal bleeding or pain.