NUR2180: Physical Assessment
Health History (5 pts total)
Biographical data: (1 pts)
No name or initial required
Age: 77 Marital status: X M S Sep. Cohab.
Birth date: 08/24/1942 Number of dependents: 0
Educational level: Bachelor’s Degree Gender: X F M Other
Occupation (current or, if retired, past): RN (retired)
Ethnicity/nationality: White
Source of history (who gave you the information and how reliable is that person): The
individual being assessed provided the information. This person is reliable.
Present health history: (4 pts)
Current medical conditions/chronic illnesses:
Current medical conditions include hypertension, hypercholesterolemia, glaucoma, and
osteopenia. Current medications:
Current medications include Losartan, Triamterene-HCTZ, Atorvastatin, Latanoprost (eye
drops) daily, and potassium and vitamin D supplements every couple days.
Medication/food/environmental allergies:
No allergies to medication, food, or anything environmental.
Past health history: (10 pts total)
Childhood illnesses: Ask about history of mumps, chickenpox, rubella, ear infections, throat
infections, pertussis, and asthma.
Childhood illnesses include pneumonia, mumps, chickenpox, and rubella.
Hospitalizations/Surgeries: Include reason for hospitalization, year, and surgical procedures.
In 1949 patient had a tonsillectomy and in 2008 a mastectomy.
Accidents/injuries: Include head injuries with loss of consciousness, fractures, motor vehicle
accidents, burns, and severe lacerations.
No previous head injuries, fractures, mortar vehicle accidents, burns, or severe trauma.
Major diseases or illnesses: Include heart problems, cancer, seizures, and any significant adult
illnesses.
Major diseases or illnesses include breast cancer, hypertension, and hypercholesterolemia.
Immunizations (dates if known):
Tetanus Diphtheria Pertussis Mumps
Rubella Polio Hepatitis B Influenza
Varicella Other
Patient has received their Tetanus, Diphtheria, Pertussis, Polio, and Influenza
immunizations. Influenza immunization was given 11/17/19 and all other dates are
unknown. Patient has not received their Rubella, Varicella, Mumps, or Hepatitis B
immunizations.
Recent travel/military services: Include travel within past year and recent and past military
service. No recent travel within the past year or past military service.
Date of last examinations:
, Physical examination 11/18/2019 Vision 09/03/2019 Dental 11/25/2019
Family History (Genogram) (10 points)
Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any major health
issues, and, if indicated, cause and age at death Present as a genogram.
Review of Systems (12 points total) Be sure to ask about symptoms specifically.
General health status (1 pt): Ask about fatigue, pain, unexplained fever, night sweats,
weakness, problems sleeping, and unexplained changes in weight. No fatigue, pain,
unexplained fever, night sweats, weakness, problems sleeping, or unexplained changes in
weight.
Integumentary (1 pt):
Skin: Ask about change in skin color/texture, excessive bruising, itching, skin lesions, sores that
do not heal, change in mole. Do you use sun screen? How much sun exposure do you
experience?
Hair: Ask about changes in hair texture and recent hair loss.
Nails: Ask about changes in nail color and texture, splitting, and cracking.
No change in skin color/texture, excessive bruising, itching, skin lesions, sores that do not
heal, or change in mole. Patient uses sunscreen and experiences about an hour of sun
exposure each day. No changes in hair texture or recent hair loss. No changes in nail color,
texture, splitting, or cracking.
HEENT (2 pts):
Head: Ask about headaches, recent head trauma, injury or surgery, history of concussion,
dizziness, and loss of consciousness. No headaches, recent head trauma, injury or surgery,
history of concussion, dizziness, or loss of consciousness.
Neck: Ask about neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the
neck. No neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the
neck.
Eyes: Ask about change in vision, eye injury, itching, excessive tearing, discharge, pain, floaters,
halos around lights, flashing lights, light sensitivity, and difficulty reading. Do you use corrective
lenses (glasses or contact lenses)? No discharge, pain, floaters, halos around lights, flashing
lights, light sensitivity, or difficulty reading. Patient was recently diagnosed with mild
cataracts. Does not use glasses or contact lenses.
Ears: Ask about last hearing test, changes in hearing, ear pain, drainage, vertigo, recurrent ear
infections, ringing in ears, excessive wax problems, use of hearing aids. No changes in hearing,
ear pain, drainage, vertigo, recurrent ear infections, ringing in ears, excessive wax
problems, or use of hearing aids. Last hearing test was normal.
Nose, Nasopharynx, Sinuses: Ask about nasal discharge, frequent nosebleeds, nasal obstruction,
snoring, postnasal drip, sneezing, allergies, use of recreational drugs, change in smell, sinus pain,
sinus infections. No nasal discharge, frequent nosebleeds, nasal obstruction, snoring,
Health History (5 pts total)
Biographical data: (1 pts)
No name or initial required
Age: 77 Marital status: X M S Sep. Cohab.
Birth date: 08/24/1942 Number of dependents: 0
Educational level: Bachelor’s Degree Gender: X F M Other
Occupation (current or, if retired, past): RN (retired)
Ethnicity/nationality: White
Source of history (who gave you the information and how reliable is that person): The
individual being assessed provided the information. This person is reliable.
Present health history: (4 pts)
Current medical conditions/chronic illnesses:
Current medical conditions include hypertension, hypercholesterolemia, glaucoma, and
osteopenia. Current medications:
Current medications include Losartan, Triamterene-HCTZ, Atorvastatin, Latanoprost (eye
drops) daily, and potassium and vitamin D supplements every couple days.
Medication/food/environmental allergies:
No allergies to medication, food, or anything environmental.
Past health history: (10 pts total)
Childhood illnesses: Ask about history of mumps, chickenpox, rubella, ear infections, throat
infections, pertussis, and asthma.
Childhood illnesses include pneumonia, mumps, chickenpox, and rubella.
Hospitalizations/Surgeries: Include reason for hospitalization, year, and surgical procedures.
In 1949 patient had a tonsillectomy and in 2008 a mastectomy.
Accidents/injuries: Include head injuries with loss of consciousness, fractures, motor vehicle
accidents, burns, and severe lacerations.
No previous head injuries, fractures, mortar vehicle accidents, burns, or severe trauma.
Major diseases or illnesses: Include heart problems, cancer, seizures, and any significant adult
illnesses.
Major diseases or illnesses include breast cancer, hypertension, and hypercholesterolemia.
Immunizations (dates if known):
Tetanus Diphtheria Pertussis Mumps
Rubella Polio Hepatitis B Influenza
Varicella Other
Patient has received their Tetanus, Diphtheria, Pertussis, Polio, and Influenza
immunizations. Influenza immunization was given 11/17/19 and all other dates are
unknown. Patient has not received their Rubella, Varicella, Mumps, or Hepatitis B
immunizations.
Recent travel/military services: Include travel within past year and recent and past military
service. No recent travel within the past year or past military service.
Date of last examinations:
, Physical examination 11/18/2019 Vision 09/03/2019 Dental 11/25/2019
Family History (Genogram) (10 points)
Mother/Father/Siblings/Grandparents: include age (date of birth, if known), any major health
issues, and, if indicated, cause and age at death Present as a genogram.
Review of Systems (12 points total) Be sure to ask about symptoms specifically.
General health status (1 pt): Ask about fatigue, pain, unexplained fever, night sweats,
weakness, problems sleeping, and unexplained changes in weight. No fatigue, pain,
unexplained fever, night sweats, weakness, problems sleeping, or unexplained changes in
weight.
Integumentary (1 pt):
Skin: Ask about change in skin color/texture, excessive bruising, itching, skin lesions, sores that
do not heal, change in mole. Do you use sun screen? How much sun exposure do you
experience?
Hair: Ask about changes in hair texture and recent hair loss.
Nails: Ask about changes in nail color and texture, splitting, and cracking.
No change in skin color/texture, excessive bruising, itching, skin lesions, sores that do not
heal, or change in mole. Patient uses sunscreen and experiences about an hour of sun
exposure each day. No changes in hair texture or recent hair loss. No changes in nail color,
texture, splitting, or cracking.
HEENT (2 pts):
Head: Ask about headaches, recent head trauma, injury or surgery, history of concussion,
dizziness, and loss of consciousness. No headaches, recent head trauma, injury or surgery,
history of concussion, dizziness, or loss of consciousness.
Neck: Ask about neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the
neck. No neck stiffness, neck pain, lymph node enlargement, and swelling or mass in the
neck.
Eyes: Ask about change in vision, eye injury, itching, excessive tearing, discharge, pain, floaters,
halos around lights, flashing lights, light sensitivity, and difficulty reading. Do you use corrective
lenses (glasses or contact lenses)? No discharge, pain, floaters, halos around lights, flashing
lights, light sensitivity, or difficulty reading. Patient was recently diagnosed with mild
cataracts. Does not use glasses or contact lenses.
Ears: Ask about last hearing test, changes in hearing, ear pain, drainage, vertigo, recurrent ear
infections, ringing in ears, excessive wax problems, use of hearing aids. No changes in hearing,
ear pain, drainage, vertigo, recurrent ear infections, ringing in ears, excessive wax
problems, or use of hearing aids. Last hearing test was normal.
Nose, Nasopharynx, Sinuses: Ask about nasal discharge, frequent nosebleeds, nasal obstruction,
snoring, postnasal drip, sneezing, allergies, use of recreational drugs, change in smell, sinus pain,
sinus infections. No nasal discharge, frequent nosebleeds, nasal obstruction, snoring,
