NRS434V.Individual Health History and Examination
Health History and Examination
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
Save this form on your computer as a Microsoft Word document. You can expand or shrink each
area as you need to include relevant data for your client.
Student Name: Sheeba Suraj Date: Feb-05-2015
Client/Patient Initials: ON Sex: Male Age: 65
Occupation of Client/Patient: Retired
Health History/Review of Systems
(Complete and systematic review of systems)
Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tinglin
difficulty speaking, difficulty swallowing, etc., medications):
• Patient mentioning no previous history of any neurological system illness.
• Patient reports head aches and back and neck pain.
• Back and neck pain begins last week after lifting and carrying some heavy objects during cleaning
his house.. Patient mentioning muscle pain too.
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck,
medications):
• Patient reports no previous history of any surgeries on head and neck or has taken any medication.
• Patient used to have common headaches related to over work and stress at his worksite and used to
take common medications. Back and neck pain related to lifting heavy objects.
Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing,
injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):
This patient reports that he never had any injury or surgery or medications related to eyes. He is doing yearly
vision test and follow up with anything necessary steps needed to take care of his vision. He reports that arou
15 years ago he had learned from his friend that having a good portion of carrots in the daily intake could hel
him to protect eyes. This patient having at least 4 to 6 carrots intake daily from last 15 years.
Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty
hearing, environmental noise exposure, vertigo, medications):
This patient never had any kind of ear related illness situations. This patient has done his ears tested a year ag
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies
surgeries, usual dental care, medications):
This patient never had any kind of nose, mouth, throat illness. He performs his annual dental checkup and
cleaning in routine. He mentioned that personal dental care is performing at very much importance like
brushing teeth at least two times a day.
Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itchin
This study source was downloaded by 100000815611969 from CourseHero.com on 11-24-2022 00:52:09 GMT -06:00
https://www.coursehero.com/file/19758786/NRS434VIndividual-Health-History-and-Examination/
, NRS434V.Individual Health History and Examination
bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications):
This patient had noticed with hair loss in last one year. He is explaining that last year the stress was so high fo
him due to some financial strains on the business. This patient mentions that he never take any serious care fo
his nails, hairs and skin. Always used regular moisturizing lotion for the skin. No visible skin diseases or
anything noted on the body. None of any major illness in the past.
Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast,
mammography, breast self-exam, medications):
No signs of any kind of illness in breasts and axilla. In the past no illness reported. Never done breast self-
exam. Educated him about doing self-breast exam and explain him the importance of conducting it.
Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs o
ankles, swollen glands, medications):
No history and signs of peripheral and lymphatic system illness to this patient.
Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of card
disease, tire easily, self-history of heart disease, medications):
This patient has a family history of cardiac disease. Father and brother of this patient died on cardiac arrest.
Patient informs that he never had any chest pain or heart disease or any kind of cardio disease histories.
Performed general inspection on the patient for breathlessness, discomfort and pain. Examined face, eyes and
mouth for signs of clinical anemia, cyanosis, xanthelasmata, corneal arcus and malar flush. Performed Palpati
of both radial pulses and assess rate and rhythm. Assessed for collapsing pulse. Palpated the right carotid puls
and assess volume and character. A high blood pressure is noted 150/90. Patient reports that recently he feels
breathlessness during his regular exercises. He said his increased blood pressure normally managed by his
physical activities and diet never had any medication for that.
Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung
disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot,
pneumococcal vaccine, chest x-ray, medications):
This patient identified self as a non-smoker and never had a habit of smoking in his life. Patient performed
yearly flu shots and chest x rays. No history of lung diseases.
Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; musc
pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity
of daily living, medications):
This patient reports that he is having joint pain on his knees. He suffers an increased pain after longer standin
He never consulted doctor for joint pain instead of that he is applying some balm whenever he suffer pain.
Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated;
abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications):
This patient reports a weight gain and increase in appetite. No previous gastrointestinal system illness reporte
Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or
straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin,
suprapubic region or low back):
No previous genitourinary system illness reported.
Physical Examination
(Comprehensive examination of each system. Record findings.)
Neurological System (exam of all 12 cranial nerves, motor and sensory assessments):
This Neurological system exam performed by Sheeba Suraj, RN at Coney Island hospital MedSurge Unit.
This patient ON 65 year’s old reported headache and neck pain and fatigue. Performed examination of 12
cranial nerves, motor and sensory assessments. Sensory and motor skills examinations performed by evaluati
walking and standing of patient. Sensory touches on hands, legs and other parts body patient identified sensor
This study source was downloaded by 100000815611969 from CourseHero.com on 11-24-2022 00:52:09 GMT -06:00
https://www.coursehero.com/file/19758786/NRS434VIndividual-Health-History-and-Examination/
Health History and Examination
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
Save this form on your computer as a Microsoft Word document. You can expand or shrink each
area as you need to include relevant data for your client.
Student Name: Sheeba Suraj Date: Feb-05-2015
Client/Patient Initials: ON Sex: Male Age: 65
Occupation of Client/Patient: Retired
Health History/Review of Systems
(Complete and systematic review of systems)
Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tinglin
difficulty speaking, difficulty swallowing, etc., medications):
• Patient mentioning no previous history of any neurological system illness.
• Patient reports head aches and back and neck pain.
• Back and neck pain begins last week after lifting and carrying some heavy objects during cleaning
his house.. Patient mentioning muscle pain too.
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck,
medications):
• Patient reports no previous history of any surgeries on head and neck or has taken any medication.
• Patient used to have common headaches related to over work and stress at his worksite and used to
take common medications. Back and neck pain related to lifting heavy objects.
Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing,
injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):
This patient reports that he never had any injury or surgery or medications related to eyes. He is doing yearly
vision test and follow up with anything necessary steps needed to take care of his vision. He reports that arou
15 years ago he had learned from his friend that having a good portion of carrots in the daily intake could hel
him to protect eyes. This patient having at least 4 to 6 carrots intake daily from last 15 years.
Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty
hearing, environmental noise exposure, vertigo, medications):
This patient never had any kind of ear related illness situations. This patient has done his ears tested a year ag
Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies
surgeries, usual dental care, medications):
This patient never had any kind of nose, mouth, throat illness. He performs his annual dental checkup and
cleaning in routine. He mentioned that personal dental care is performing at very much importance like
brushing teeth at least two times a day.
Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itchin
This study source was downloaded by 100000815611969 from CourseHero.com on 11-24-2022 00:52:09 GMT -06:00
https://www.coursehero.com/file/19758786/NRS434VIndividual-Health-History-and-Examination/
, NRS434V.Individual Health History and Examination
bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications):
This patient had noticed with hair loss in last one year. He is explaining that last year the stress was so high fo
him due to some financial strains on the business. This patient mentions that he never take any serious care fo
his nails, hairs and skin. Always used regular moisturizing lotion for the skin. No visible skin diseases or
anything noted on the body. None of any major illness in the past.
Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast,
mammography, breast self-exam, medications):
No signs of any kind of illness in breasts and axilla. In the past no illness reported. Never done breast self-
exam. Educated him about doing self-breast exam and explain him the importance of conducting it.
Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs o
ankles, swollen glands, medications):
No history and signs of peripheral and lymphatic system illness to this patient.
Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of card
disease, tire easily, self-history of heart disease, medications):
This patient has a family history of cardiac disease. Father and brother of this patient died on cardiac arrest.
Patient informs that he never had any chest pain or heart disease or any kind of cardio disease histories.
Performed general inspection on the patient for breathlessness, discomfort and pain. Examined face, eyes and
mouth for signs of clinical anemia, cyanosis, xanthelasmata, corneal arcus and malar flush. Performed Palpati
of both radial pulses and assess rate and rhythm. Assessed for collapsing pulse. Palpated the right carotid puls
and assess volume and character. A high blood pressure is noted 150/90. Patient reports that recently he feels
breathlessness during his regular exercises. He said his increased blood pressure normally managed by his
physical activities and diet never had any medication for that.
Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung
disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot,
pneumococcal vaccine, chest x-ray, medications):
This patient identified self as a non-smoker and never had a habit of smoking in his life. Patient performed
yearly flu shots and chest x rays. No history of lung diseases.
Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; musc
pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity
of daily living, medications):
This patient reports that he is having joint pain on his knees. He suffers an increased pain after longer standin
He never consulted doctor for joint pain instead of that he is applying some balm whenever he suffer pain.
Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated;
abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications):
This patient reports a weight gain and increase in appetite. No previous gastrointestinal system illness reporte
Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or
straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin,
suprapubic region or low back):
No previous genitourinary system illness reported.
Physical Examination
(Comprehensive examination of each system. Record findings.)
Neurological System (exam of all 12 cranial nerves, motor and sensory assessments):
This Neurological system exam performed by Sheeba Suraj, RN at Coney Island hospital MedSurge Unit.
This patient ON 65 year’s old reported headache and neck pain and fatigue. Performed examination of 12
cranial nerves, motor and sensory assessments. Sensory and motor skills examinations performed by evaluati
walking and standing of patient. Sensory touches on hands, legs and other parts body patient identified sensor
This study source was downloaded by 100000815611969 from CourseHero.com on 11-24-2022 00:52:09 GMT -06:00
https://www.coursehero.com/file/19758786/NRS434VIndividual-Health-History-and-Examination/
