For this assignment writer was asked to perform a physical assessment on an elderly
patient. Writer was able to perform assessment on her neighbor. This paper will go over the
health history with review of systems, a functional health pattern assessment and a SBAR
to conclude and review present issue.
Health History and Examination
Student Name: Date: Nov, 2015
Client/Patient Initials: B.R. Sex: Female Age: 58
Occupation of Client/Patient: Stay at home Mom and Part time Secretary for home school
Health History/Review of Systems
Neurological System:
Patient states having minor headaches maybe once a month (Thinks that it is related to allergies)
Has no history of head injuries, dizziness, convulsions, tremors, unexplained weakness,
numbness or tingling. No reports of having difficulty speaking or swallowing.
Head and Neck:
Patient reports having no pain in head or neck.
Headaches reported monthly, patient thinks related to allergies. Patient denies head/neck injury,
neck pain, lumps/swelling, surgeries on head/neck.
Eyes
Patient denies eye pain, blurred vision, history of crossed eyes, watering, tearing or
injury/surgery to eye.
Patient does have redness in eyes related to seasonal allergies. Patient uses Visine for redness
and irritation.
Last eye exam was March 2015-Patient denies glaucoma. States that she uses reading glasses
with the prescription of +3. States that she only needed them when reading or doing
computer work. Denies using contact.
Ears:
Patient denies earache or other ear pain, history of ear infections, discharge from ears. Denies
history of surgery, vertigo or difficulty hearing.
Denies having long periods of environmental noise exposure.
No medications taken
Nose, Mouth, and Throat:
Patient denies discharge, sores or lesions, nosebleeds, bleeding gums, or sore throat.
States having seasonal allergies and takes Claritin PRN.
Denies Surgeries
Patient states that she has her teeth cleaned every 6 months. Had no cavities last exam.
This study source was downloaded by 100000852681095 from CourseHero.com on 11-26-2022 05:19:15 GMT -06:00
https://www.coursehero.com/file/13078620/Health-History-and-Exam-with-SBAR-NRS-434V/
, Skin, Hair and Nails:
Patient denies skin disease, changes in color, changes in a mole, excessive dryness or moisture,
itching, bruising, rashes or lesions, recent hair loss, changing nails, or any environmental
hazards/exposures.
Denies taking medications.
Hair is washed every other day. No dandruff upon inspection.
Breasts and Axilla:
Patient denies pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to
breast or axilla.
Mammography done Oct 2014- no abnormal findings or concerns
Patient states that she performs self-breast exams monthly in the
shower.
Peripheral Vascular and Lymphatic System:
Patient denies leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, or
swollen glands.
Denies taking medications.
Cardiovascular System:
Patient denies chest pain or tightness, SOB, cough, swelling of feet or hands or tiring easily.
Has a family history of cardiac disease in her father at the age of 60.
Patient denies taking cardiac medications
Thorax and Lungs:
Patient denies coughing, SOB, pain on inspiration or expiration, chest pain with breathing,
history of lung disease, living/working conditions that affect breathing,
Smoking history- Patient states that she smoked for about 3 years while in college. Smokes
occasionally when she is drinking but denies doing that in years.
last TB skin test was 2 years ago for her physical exam for the
school flu shot- Sept 2015
pneumococcal vaccine- Patient denies
chest x-ray- patient does not remember
Denies taking medications.
Musculoskeletal System:
Denies joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle
pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty
with activity of daily living.
Denies taking medications for musculoskeletal issues.
Gastrointestinal System:
Patient denies change in appetite – increase or loss. Denies difficulty swallowing food. Has no
issues with foods not tolerated. Denies abdominal pain; nausea or vomiting; No history of GI
disease or ulcers.
Frequency of BM- Patient states having a BM every other day, no concerns with constipation or
hemorrhoids. Patient denies taking medications.
This study source was downloaded by 100000852681095 from CourseHero.com on 11-26-2022 05:19:15 GMT -06:00
https://www.coursehero.com/file/13078620/Health-History-and-Exam-with-SBAR-NRS-434V/
patient. Writer was able to perform assessment on her neighbor. This paper will go over the
health history with review of systems, a functional health pattern assessment and a SBAR
to conclude and review present issue.
Health History and Examination
Student Name: Date: Nov, 2015
Client/Patient Initials: B.R. Sex: Female Age: 58
Occupation of Client/Patient: Stay at home Mom and Part time Secretary for home school
Health History/Review of Systems
Neurological System:
Patient states having minor headaches maybe once a month (Thinks that it is related to allergies)
Has no history of head injuries, dizziness, convulsions, tremors, unexplained weakness,
numbness or tingling. No reports of having difficulty speaking or swallowing.
Head and Neck:
Patient reports having no pain in head or neck.
Headaches reported monthly, patient thinks related to allergies. Patient denies head/neck injury,
neck pain, lumps/swelling, surgeries on head/neck.
Eyes
Patient denies eye pain, blurred vision, history of crossed eyes, watering, tearing or
injury/surgery to eye.
Patient does have redness in eyes related to seasonal allergies. Patient uses Visine for redness
and irritation.
Last eye exam was March 2015-Patient denies glaucoma. States that she uses reading glasses
with the prescription of +3. States that she only needed them when reading or doing
computer work. Denies using contact.
Ears:
Patient denies earache or other ear pain, history of ear infections, discharge from ears. Denies
history of surgery, vertigo or difficulty hearing.
Denies having long periods of environmental noise exposure.
No medications taken
Nose, Mouth, and Throat:
Patient denies discharge, sores or lesions, nosebleeds, bleeding gums, or sore throat.
States having seasonal allergies and takes Claritin PRN.
Denies Surgeries
Patient states that she has her teeth cleaned every 6 months. Had no cavities last exam.
This study source was downloaded by 100000852681095 from CourseHero.com on 11-26-2022 05:19:15 GMT -06:00
https://www.coursehero.com/file/13078620/Health-History-and-Exam-with-SBAR-NRS-434V/
, Skin, Hair and Nails:
Patient denies skin disease, changes in color, changes in a mole, excessive dryness or moisture,
itching, bruising, rashes or lesions, recent hair loss, changing nails, or any environmental
hazards/exposures.
Denies taking medications.
Hair is washed every other day. No dandruff upon inspection.
Breasts and Axilla:
Patient denies pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to
breast or axilla.
Mammography done Oct 2014- no abnormal findings or concerns
Patient states that she performs self-breast exams monthly in the
shower.
Peripheral Vascular and Lymphatic System:
Patient denies leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, or
swollen glands.
Denies taking medications.
Cardiovascular System:
Patient denies chest pain or tightness, SOB, cough, swelling of feet or hands or tiring easily.
Has a family history of cardiac disease in her father at the age of 60.
Patient denies taking cardiac medications
Thorax and Lungs:
Patient denies coughing, SOB, pain on inspiration or expiration, chest pain with breathing,
history of lung disease, living/working conditions that affect breathing,
Smoking history- Patient states that she smoked for about 3 years while in college. Smokes
occasionally when she is drinking but denies doing that in years.
last TB skin test was 2 years ago for her physical exam for the
school flu shot- Sept 2015
pneumococcal vaccine- Patient denies
chest x-ray- patient does not remember
Denies taking medications.
Musculoskeletal System:
Denies joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle
pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty
with activity of daily living.
Denies taking medications for musculoskeletal issues.
Gastrointestinal System:
Patient denies change in appetite – increase or loss. Denies difficulty swallowing food. Has no
issues with foods not tolerated. Denies abdominal pain; nausea or vomiting; No history of GI
disease or ulcers.
Frequency of BM- Patient states having a BM every other day, no concerns with constipation or
hemorrhoids. Patient denies taking medications.
This study source was downloaded by 100000852681095 from CourseHero.com on 11-26-2022 05:19:15 GMT -06:00
https://www.coursehero.com/file/13078620/Health-History-and-Exam-with-SBAR-NRS-434V/
