Health History and Screening of an Adolescent or Young Adult Client

[Name of Student]

Health History and Screening of an Adolescent or Young Adult Client

Health History and Examination

18th April 2103

Client/Patient Initials: Y.T.

Sex: Male

Age: 15 years

Occupation of Client/Patient: High School Student

Health History/Review of Systems

(Complete and systematic review of systems)

Neurological System: Normal with slight headaches at times.

Head, Eye, Nose and Ears: Previous ENT reports are normal showing no abnormalities, Weak Vision

Skin, Hair and Nails: Normal

Breasts and Aureoles: Normal

Peripheral Vascular and Lymphatic System: No abnormalities

Cardiovascular System: no abnormalities

Thorax and Lungs: Healthy chest

Musculoskeletal System: Cramping due to excessive heavy weight exercises in the past

Gastrointestinal System: Healthy appetite

Genitourinary System: Normal

Physical Examination

(Comprehensive examination of each system. Record findings.)

Neurological System: Migraine headache present. CT Scan showed normal results. Signs of Seizure present. Pupil dilates

Head and Neck: Normal

Eyes and Ears: Blurred vision and Normal hearing, no abnormalities seen in the ear

Nose, Mouth, and Throat: Tongue Laceration is seen that indicates presence of previous seizers.

Skin, Hair and Nails Sweaty and pale skin, Yellowish texture of the nails.

Peripheral Vascular and Lymphatic System: No abnormalities present

Cardiovascular System and Chest: X-ray was taken to observe the conditions of both heart and chest. Signs of pneumonia present. ECG shows high pulse rate in the patient. Respiratory distress and dry cough is present. ECG shows that no murmurs are present.

Musculoskeletal System: Normal results with no signs of fractures.

Gastrointestinal System: Rectal examination shows presence of GI bleeding.

FHP Assessment

Cognition

Consciousness intensity: Lethargic and Drowsy

Mood: Irritable, anxious and fearful

Affect: anger, fear and blunt

Eye movement: abnormalPupil size: Dilated

Grip: weak and feebleRight: weakleft: weak

Right hand push/pull strength: strong/weak left: strong/weak

Other: hyperactivity with increased pulse rate.

Pain: yesDenies: yes

Location: Lower abdomen pain, acute to chronic at times.

Intensity on scale: 7

When did pain begin? On the 2nd day of withdrawal in the morning, once or twice per day

What improved pain? Aspirin

Contemplation: hallucinations

Mood and Behavior: mood swings with violent behavior

Touch: abnormal: describe: shiver in the hands

Decisions making ability: moderately difficult

Nutrition and Metabolism

Height: 5 feet 8 inches Weight: 50kg Weight vacillation (last 6 months): 8 to 10kg

Diet intake: Regular diet but with withdrawal is malnourished.

Desire for food: DecreasedDecreased taste: yes

Nausea: Yes Describe: Severe

Swallowing complexity: Secretion of Saliva decreases,

Feeding: Self

Oral condition: dry with a little amount of saliva

Teeth /gums: plaque is present in the teeth and gums

Skin Condition: Sweatycolor: pallor

Temperature: hot

Bruises: 1 bruise and some scratches describe: (size, location): ...