Health History and Physical Assessment

So you read this first part and finish up the highlighted part at the bottom.

Health History and Physical Assessment

This paper is a narrative of an assessment and health history of a patient. In order to accomplish this, the Jarvis text, Physical Examination & Health Assessment was reviewed.

Health History: Subjective Data

Patient is a 65 year old African American male who has come to the clinic for a routine, annual physical exam. Present illnesses are hypertension and obesity. Perception of health is poor as the patient believes himself to be healthy therefore he does not need any further care beyond annual physical exams. Patient has a PMH of smoking and seasonal allergies. Patient reports that he takes benadryl and claritin during the fall months. He is up to date on all vaccinations. He has a history of hypertension for which he takes lisinopril. His hypertension is well controlled. FMH includes paternal lung cancer and maternal hypertension. Both parents are deceased. Patient reports no neurological symptoms. He is alert and oriented to self, time, situation, and place. He occasionally takes aspirin for headaches. Patient is developmentally typical for his age. Cultural considerations include that he is African American and therefore at higher risk for hypertension. Patient is married and has an active social life with friends and coworkers. Patient has no children. In his free time, he enjoys playing music with a group of friends. Collaborative resources could include a dietician, family involvement, physical trainer, and smoking cessation resources.

Physical Examination: Objective Data

Patient’s head appears to be symmetrical and appropriately sized for his stature. The structures appear to be symmetrical. No wounds, lesions, or incisions noted on the head. Patient has no piercings or tattoos. Eyes display PERRLA bilaterally. Ears free of discharge and passed whisper test bilaterally. Nose free of deformities and discharge. Inner mucous membranes of the mouth and throat noted to be pink and moist. Teeth are intact with none missing or broken. Upon palpation of the neck, no masses can be felt. Trachea is midline. No lymph nodes can be palpated. Increased lung sounds can be heard upon auscultation. Oxygen saturation measured at 98% of room air. Patient is hypertensive with a blood pressure reading of 139/90. Pulse rate measured at 75 and is 2+. Patient is alert and oriented x4. Bowel sounds can be auscultated at fifteen sounds per minute. The patient can move all joints through the full range of motion with no assistance. No edema noted upon inspection of extremities. All pulses palpated bilaterally and are 2+. No wounds, lesions, or incisions noted on the skin throughout the assessment. Skin color was appropriate for the patient’s ethnicity and it was warm and dry to the touch. Skin turgor test showed no tenting of the skin.

Needs Assessment

Based on the health history and physical examination findings, determine at least two health education needs for the individual. Remember, you may identify an educational topic that is focused on wellness. Support the identified health teaching needs selected with evidence from two current, peer-reviewed journal articles. Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education. Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) effect proposed teaching.