Health Assessment

Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems

Neurological System: headaches, weakness, numbness, convulsions, medications.
Head and Neck: neck pain, previous head surgery, pain inside the head, medications.
Eyes: eye pain, redness of eyes, watering, vision testing, put on glasses, history of medication.
Ears: a history of ear infection and medication.
Nose, Mouth, and Throat: nosebleeds, bleeding gums, history of a sore throat, allergic to wheat (gluten), medications.
Skin, Hair, and Nails: excessive dryness of skin, dark nails, itching skin, recent hair loss, history of nutrition supplementation.
Breasts and Axilla: None
Peripheral Vascular and Lymphatic System: swelling legs, medication.
Cardiovascular System: family history of cardiac disease, self-history of heart disease, chest pain, medication.
Thorax and Lungs: smoking history, pain on inspiration, chest x-ray and medication.
Musculoskeletal System: joint pain due to a previous car accident, limitation of movement, difficulty with the activity of daily living, medication.
Gastrointestinal System: Normal.
Genitourinary System: Normal.

Physical Examination

(Comprehensive examination of each system. Record findings.) Neurological System: the patient’s twelve cranial nerves were examined. Also did an assessment of sensory and motor sensory nerves.

Situation

Numbness, headaches, convulsions, and weakness.

Background

The problem started one year ago and the patient reported having a history of seasonal numbness and the symptoms were mostly triggered by emotional stress. A few of the cranial nerves were under stress resulting in headaches and sometimes temporal loss of memory.

Assessment

During a physical examination, all the twelve cranial nerves were assessed separately. The patient was given scratch papers that were scented to smell and it was normal. The optic nerve function was tested by use of the Snellen chart to test for acuity, perimetry, and use of confrontation method tested for visual fields, and lastly, multicolor materials were used to test if he could identify the different colors. The oculomotor nerve was assessed and was normal because the patient had no problems with eye rotation, the trochlear nerve was tested by asking the patient if he was able to view his nose's tip. The trigeminal nerve was found to be normal by testing the ease of jaw movement. Objects were put at a point and the patient instructed to locate them, hence testing for the abducens nerve. The facial nerve was tested by testing the tongues sense of taste. Vestibulocochlear nerve function was tested by exposing the patient to different sounds and asking him to differentiate the sounds. Glossophary and vagus nerves were tested and found to be partially paralyzed causing the numbness and seasonal appetite loss of the patient. Sensory nerves were tested by touching the skin with an object and the patient responded when some parts were touched. He was partially numb on the left side. The motor nerves functioning were tested by checking if there was a depression on the patient's muscle and some depressions were found in both legs which were a result of a car accident. This caused weakness and pain during walking.

Recommendation

The patient was to be enrolled to start physiotherapy programs patient was to be put on medication as a continuation of the medicine taken previous so as to manage the complications.

Head and Neck

Situation

Neck pain, previous head surgery, pain inside the head, medications.

Background

The patient has a history of a car accident which caused him some neck and head injuries. He also went through a head surgery.

Assessment

To palpate the lymph nodes, a firm pressure is applied gently using the pads of the four fingers. If the lymph nodes are extra-large and can be seen expanding on the skin, then there is accumulation which causes the white blood cells to malfunction. The skull was palpated by slowly passaging the skull and being keen at the joints. The patent had broken thyroid cartilage which was caused by the accident. The thyroid was tested by the patient swallowing water and its size was normal.

Recommendation

More check-up was required to watch the progress of healing of the accident injuries.

Eyes

Situation

Eye pain, redness of eyes, watering, vision testing, puts on glasses, history of medication.

Background

Family history of eyes problems.

Assessment

The visual acuity was tested, by having the patient stand at different distances to read words of different sizes. He complained of straining reading and that the light was too bright and yet the light was normal. He had no refractive error when the pinhole testing was done. The external eye structures and the anterior eyeball structures were inspected and found to be normal. The ocular fundus was viewed from different angles of light and found to be normal.

Recommendation

The patient's eye pain was due to abnormal light response and was to be booked for more check up and medication. This is because that was the probable cause of the eye pain.

Ears

Situation

Seasonal ear pain

Background

History of an ear infection which had been caused by an accumulation of wax.

Assessment

All the external structures were checked. There was a scar of a previous swelling in the external canal of the patient ear which was healing.

Recommendation

The patient’s ear was to be closely monitored to avoid recurrence of the infection. Nose, Mouth, and Throat

Situation

Nosebleeds, history of a sore throat, medication.

Background

The patient reported having incidences of nosebleeds and currently experiencing a sore throat.

Assessment

Did nose, and sinus palpation then inspected the throat and mouth. Noticed the presence of large tonsils.

Recommendation

Treatment of tonsils and monitor in case of recurrence of nose bleeding.

Skin, Hair, and Nails

Situation

Excessive dryness of skin, dark nails, history of itching skin, recent hair loss.

Background

History of itching skin. Still experienced excessive dryness but under medication.

Assessment

Clinical inspection of the skin moisture level, lesions, the temperature was done and the moisture content was still low. The patient’s hair had poor distribution and the nails were dark colored due to blood clots beneath.

Peripheral Vascular and Lymphatic System

Situation

Swelling legs, medication.

Background

History of swollen limbs.

Assessment

The limbs, vein pattern, symmetry, varicosities, and pulses were inspected. The legs were swollen.

Recommendation

Low sodium diet and continuation of medication.

Cardiovascular System

Situation

Family history of cardiac disease, self-history of heart disease, chest pain, medication.

Background

A family history of cardiac disease.

Assessment

All blood vessels inspected and deposition observer in the coronary artery walls.

Recommendation

Increase frequent exercise with a regular checkup. Adherence to medication. To reduce intake of foods with saturated fats.

Thorax and Lungs

Situation

Pain on inspiration, chest x-ray, and medication.

Background

Smoking history

Assessment

Chest X-ray was done and blurry chest observed.

Recommendation

Medication and monitor any withdrawal symptoms.

Musculoskeletal System

Situation

Joint pain due to a previous car accident, limitation of movement, difficulty with the activity of daily living, medication.

Background

History of a car accident which caused fractures and injuries.

Assessment

C.T scan of most affected body parts. X-ray done to fractured bones.

Recommendation

Frequent check-ups and exercise. High protein diet to replace broken tissues.

Gastrointestinal System: Normal.

Genitourinary System (deferred for purpose of this class)

FHP Assessment

Cognitive-Perceptual Pattern: The patient was able to describe his current health and he reported a great improvement since the accident. He said he was adhering to his previously given medication and was doing a routine exercise. He was able to finance his medication. He said his family has a history of heart problems.

Nutritional-Metabolic Pattern:

The patient was overweight but reported of weighing more before then. According to the dietary assessment, the patient still had a struggle of letting junk food completely off his diet although the fruit intake was commendable.

Sexuality-Reproductive Pattern:

No sexual dysfunction and satisfied with his sexual life.

Pattern of Elimination

The patient produces less sweat than normal and experiences nocturnuria. Has dry skin and no digestive complication.

The pattern of Activity and Exercise:

No discipline in the set routine exercise. Pattern of Sleep and Rest: Normal Pattern of Self-Perception and Self-Concept: Normal

Summarize Your Findings

Situation

The patient experienced chest tightness and sought for care. He was also still nursing car accident injuries.

Background

The family had a history of heart problems.

Assessment

The patient underwent systematic assessment of all body systems and the source of the reported complaints were found.

Recommendation

The different diagnosis made was evaluated and the patient put under health care program and close follow-up. Patient education and health promotion done.

Reference

Bates, B., & Bickley, L. S. (2014). Guide to the clinical examination (11th US edition/7th French edition).