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

Case: Mrs. Fiona Albert is a 65 year old female patient. She was diagnosed with the type II diabetes ten years ago. Her sugar level was found 390 mg/dl, a hyperglycemic state. She was rushed to the hospital with a condition of intense vomiting and hyperglycemia; and admitted.

Client/Patient Initials: Mrs. Fiona Albert

Sex: Female

Age: 56 years

Occupation of Client/Patient: House wife

Health History/Review of Systems

(Complete and systematic review of systems)

Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications):

Feel numbness often in the legs but does not take any medication.

Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications):

Normal, no pain, injury or numbness in head and neck.

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):

Wear glasses.

Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications):

Normal

Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications):

Nose and mouth are normal, no allergies, bleeding, pain and lesions.

Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications):

Skin and hair are normal. N o disease found. There is a small spot present on right toe nail which has no any color.

Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications):

Normal. No lumps, swelling, rash, and injury.

Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications):

Pain in both legs and she has intense pain that she cannot sleep at night.

Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications):

She has no any complain regarding cardiovascular disorders.

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):

No cough and has normal breathing rate. She is not a smoker.

Musculoskeletal System (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, medications):

No swelling, stiffness, pain in joints but intense pain in legs. She likes the winter season and shows intolerance to heat.

Gastrointestinal System (change in appetite - increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of ...