Client/Patient Initials: DN| Sexual activity: M| Age: 66 | Occupation of Client/Patient: Retired|
Health History/Review of Systems ( Complete and systematic reappraisal of systems ) | Neurological System ( concerns. caput hurts. giddiness. paroxysms. shudders. failing. numbness. prickling. trouble speech production. trouble get downing. etc. . medicines ) : No ailments of concerns. no past caput hurts. no ailments of giddiness. no history of paroxysm. shudders or failing. The patient states he has had no numbness. prickling. or unsteady pace. The patient denies dysphagia or dysphasia. | Head and Neck ( hurting. concerns. head/neck hurt. cervix hurting. lumps/swelling. surgeries on head/neck. medicines ) : The patient denies caput hurting. caput or neck hurt or injury. no nodules or surgeries. The patient denies taking medicine for caput or cervix. | Eyes ( oculus hurting. blurred vision. history of crossed eyes. redness/swelling in eyes. irrigating. rupturing. injury/surgery to oculus. glaucoma proving. vision trial. spectacless or contacts. medicines ) : The patient does wear disciplinary spectacless.

The patient denies inflammation or swelling in eyes nor lacrimation. The patient denies history of oculus hurt or surgery. | Ears ( otalgia or other ear hurting. history of ear infections. discharge from ears. history of surgery. trouble hearing. environmental noise exposure. dizziness. medicines ) : The patient denies ear hurting or recent ear infections. The patient does hold a patch to right ear saying he merely “had skin malignant neoplastic disease removed” . Incision integral. No environing inflammation or swelling. The patient denies drainage. The patient denies vertigo. | Nose. Mouth. and Throat ( discharge. sores or lesions. hurting. epistaxiss. shed blooding gums. sore pharynx. allergic reactions. surgeries. usual dental attention. medicines ) : The patient denies sore pharynx. runny nose. or sores to talk. The patient has hapless teething and states he sees a tooth doctor on a regular basis.

The patient states he brushes his teeth twice daily. The patient denies seasonal allergic reactions. | Skin. Hair and Nails ( skin disease. alterations in colour. alterations in a mole. inordinate waterlessness or wet. itchiness. bruising. roseola or lesions. recent hair loss. altering nails. environmental hazards/exposures. medicines ) : The patient denies inordinate waterlessness or inordinate wet to clamber. The patient provinces history of tegument malignant neoplastic disease. The patient states he has had several “spots removed” for tegument malignant neoplastic disease including his olfactory organ. right ear. and cheek. The patient denies contusing easy. | Breasts and Axilla ( hurting or tenderness. balls. nipple discharge. roseola. swelling. injury or hurt to breast. mammography. breast self-exam. medicines ) : The patient denies pain or tenderness to chests. The patient denies rash or swelling to chests. | Peripheral Vascular and Lymphatic System ( leg hurting. spasms. tegument alterations in weaponries or legs. swelling in legs or mortise joints. conceited secretory organs. medicines ) : The patient denies leg hurting or cramping. The patient denies swelling in lower appendages and denies taking medicines to increase circulation. | Cardiovascular System ( chest hurting or stringency. SOB. cough. swelling of pess or custodies. household history of cardiac disease. tyre easy. self-history of bosom disease. medicines ) : The patient states he has a history of bosom onslaught and high blood force per unit area. The patient denies shortness of breath or recent thorax hurting. The patient states he presently takes Coreg and Aspirin daily. | Thorax and Lungs ( cough. SOB. hurting on inspiration or termination. chest hurting with external respiration. history of lung disease. smoking history. living/working conditions that affect take a breathing. last TB skin trial. grippe shooting. pneumococcal vaccinum. chest x-ray. medicines ) : The patient denies cough or shortness of breath. The patient denies chest hurting upon inspiration or termination.

The patient denies lung disease. The patient states he stopped smoking 32 old ages ago. The patient states he is up to day of the month on his flu inoculation every bit good as his pneumonia inoculation. | Musculoskeletal System ( joint hurting ; stiffness ; swelling. heat. inflammation in articulations ; restriction of motion ; musculus hurting or cramping ; malformation of bone or articulation ; accidents or injury to castanetss ; back hurting ; trouble with activity of day-to-day life. medicines ) : The patient denies joint hurting or stiffness. The patient denies muscle hurting or cramping. The patient denies malformation of castanetss or joint. The patient denies history of injury or accident to castanetss or musculus. The patient denies enervation to activities of day-to-day life. | Gastrointestinal System ( alteration in appetite – addition or loss ; trouble swallowing ; nutrients non tolerated ; abdominal hurting ; sickness or emesis ; frequence of BM ; history of GI disease. ulcers. medicines ) : The patient denies alterations in appetency. The patient denies trouble get downing. The patient denies nutrients that are non tolerated. The patient denies frequent sickness or emesis. The patient states he has a regular intestine motion daily. The patient denies history of GI ulcers or taking medicines for GERD or acerb reflux. | Genitourinary System ( recent alteration. frequence. urgency. nycturia. dysuria. polyuria. oliguria. hesitance or straining. urine colour. narrowed watercourse. incontinency. history of urinary disease. hurting in wing. inguen. suprapubic part or low back ) : The patient denies urgency. frequence. or dysuria. The patient denies polyuria.

The patient provinces history of kidney rocks. The patient denies incontinency or wing hurting. The patient denies groin hurting or low back hurting. | Physical Examination ( Comprehensive scrutiny of each system. Record findings. ) | Neurological System ( test of all 12 cranial nervousnesss. motor and centripetal appraisals ) : Cranial Nerve I – Sense of odor integral evidenced by smelling an onion every bit good as cinnamon with eyes closed. Cranial Nerve II – Snellen oculus chart oculus test shower 20/40 in bilateral eyes without disciplinary lenses. Patient is 20/20 in bilateral eyes with disciplinary lenses. Cranial Nerve II. IV. and VI – Pupils equal. unit of ammunition. and reactive to light and adjustment. Extraocular motions are within normal bounds. Cranial Nerve V – Mastication musculuss are equal bilaterally. Cranial Nerve VII – Facial symmetricalness noted. Facial nervousnesss map appears within normal bounds. Cranial Nerve VIII – Normal hearing functioned noted with hearing soft spoken words every bit good as normal conversation. Cranial Nerve IX and X – The patient has a positive joke physiological reaction every bit good as normal looking uvula and soft roof of the mouth. Cranial Nerve XI – The sternocleido mastoideus and cowl muscle musculuss are symmetric. Neck and caput with full scope of gesture. Shoulder shrug demoing trapezius musculus equal bilaterally. Cranial Nerve XII – The patient’s address is within normal bounds with a midplane lingua. No sores. lesions. or abnormalcies of lingua noted. | Head and Neck ( feel the skull. inspect the cervix. inspect the face. feel the lymph nodes. feel the windpipe. palpate and auscultate the thyroid secretory organ ) : Face is symmetric.

Trachea is midline. Lymph nodes within normal bounds with no goitre noted. The patient has full scope of gesture to caput and cervix. The patient’s caput is without nodules noted. The patient has strong carotid pulsations present bilaterally. | Eyes ( test ocular sharp-sightedness. ocular Fieldss. extraocular musculus map. inspect external oculus constructions. inspect anterior orb constructions. inspect optic fundus ) : Patient is 20/20 in bilateral eyes with disciplinary lenses. Extraocular motions are integral. No nystagimus or squint noted. Students are equal. unit of ammunition. and reactive to light and adjustment. No drainage or inflammation noted to bilateral eyes. Conjunctiva are pink. sclerotic coat white without inflammation noted. | Ears ( inspect external construction. otoscopic scrutiny. inspect tympanic membrane. trial hearing sharp-sightedness ) : The patient’s ears are symmetric. The patient has a dressing to right ear from recent tegument malignant neoplastic disease remotion. Incision clear without inflammation or drainage. The patient’s hearing within normal bounds. Bilateral tympanic membranes integral and pearly grey with normal light physiological reaction. No perforations noted. Ear canal free of drainage. | Nose. Mouth. and Throat ( Inspect and feel the olfactory organ. feel the sinus country. inspect the oral cavity. inspect the pharynx ) : The patient’s olfactory organ is symmetric with no rhinal drainage noted. Nasal septum midplane. The patient denies tenderness of the external nares. Nasal mucous membrane is pink and within normal bounds. Nares patent. No rhinal flaring noted. Mouth within normal bounds with no sores or blisters noted to tongue. Tongue is midline. Tonsils are pink with no swelling noted. The patient has no dental cavities noted. but several fillings noted. | Skin. Hair and Nails ( inspect and palpate tegument. temperature. wet. lesions. inspect and palpate hair. distribution. texture. inspect and palpate nails. contour. colour. learn introspection techniques ) : The patient’s tegument with no waterlessness. roseolas. or acne noted.

The patient has a cicatrix noted to his olfactory organ. right ear. and left cheek. The patient provinces this is countries of tegument malignant neoplastic disease that have been removed. Skin turgor within normal bounds with no camping. The patient’s hair is thin with no marks of dandruff. The patient’s nails are non brittle. No clubbing noted. Capillary refill is less than three seconds. | Breasts and Axilla ( deferred for intent of category assignment ) | Peripheral Vascular and Lymphatic System ( inspect weaponries. symmetricalness. pulsations ; inspect legs. venous form. varicosities. pulsations. colour. swelling. balls ) : The patient has no swelling noted to upper or lower appendages. Skin colour within normal bounds with no stain. Peripheral pulsations are strong and equal bilaterally. The patient’s legs are without varicosities. | Cardiovascular System ( inspect and palpate carotid arterias. jugular venous system. precordium heaving or lift. apical urge ; auscultate rate and beat ; place S1 and S2. any excess bosom sounds. mutter ) : The patient’s blood force per unit area is 128/78. pulse 68. Upon auscultation. the apical pulsation is besides 68 with regular rate and beat. No mutter or arrhythmia noted. S1 and S2 noted without mutter. No bruit noted.

No jugular vena dilatation noted. | Thorax and Lungs ( inspect thoracic coop. symmetricalness. haptic fremitus. windpipe ; feel symmetrical enlargement ; . percussion of anterior. sidelong and posterior. unnatural take a breathing sounds ) : The patient’s thorax has equal and bilateral rise and autumn with good musculus tone. The patient denies chest tenderness upon tactual exploration. Respiratory rate 17 breaths per minute and regular. Tactile fremitus symmetrical over posterior lung country of the dorsum. Lungs sounds clear in all four lobes. | Musculoskeletal System ( inspect cervical spinal column for size. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect shoulders for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect cubituss for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect carpus and custodies for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect hips for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect articulatio genuss for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect mortise joints and pess for size. colour. contour. swelling. mass. malformation. hurting and scope of gesture ) : The patient has no curvature noted to spine. The spinal column is without swelling or malformation. The patient denies cervical tenderness or hurting. The patient’s shoulders are symmetric with full scope of gesture. The patient’s cubituss are free of malformation with full scope of gesture. The patient denies pain to cubituss. The patient’s carpus are free of malformation with full scope of gesture. The patient denies pain to carpuss. The patient’s custodies are free of malformation with full scope of gesture. The patient denies pain to custodies. The patient has healed cicatrixs from bilateral carpal tunnel surgery. The patient’s hips are symmetric with full scope of gesture.

The patient denies pain to hips. The patient’s articulatio genuss are symmetric with full scope of gesture. No multitudes or malformations noted. The patient denies pain to articulatio genuss. The patient’s articulatio genuss are symmetric without obvious multitudes. The patient has full scope of gesture to bilateral articulatio genuss. The patient denies pain to bilateral articulatio genuss. The patient’s pess are without swelling. The patient has full scope of gesture to ankle and pick. No obvious malformations or multitudes noted. Skin is integral to bilateral pess. ( Jarvis. 2012 ) . | Gastrointestinal System ( contour of venters. general symmetricalness. skin colour and status. pulsing and motion. navel. hair distribution ; auscultate intestine sound ; . percuss all four quarter-circles ; percuss boundary line of liver ; light tactual exploration in all four quadrants– musculus wall. tenderness. hypertrophied variety meats. multitudes. bounce tenderness. CVA tenderness ) : The patient’s venters is symmetric. soft. and unit of ammunition. The patient has normal hair distribution with skin pink. The patient denies tenderness to all four quarter-circles. Bowel sounds normoactive x4 quarter-circles. No multitudes palpated. Liver palpates within normal bounds. | Genitourinary System ( deferred for intent of this category ) | FHP Assessment|

Cognitive-Perceptual Form: The patient has no cognitive defects noted. | Nutritional-Metabolic Form: The patient states he eats breakfast. tiffin. and dinner. The patient states he tries to watch what he eats. He does nevertheless province he has a failing for ice pick. | Sexuality-Reproductive Form: The patient states he has been married to his married woman for 28 old ages. He denies jobs or issues with his sex life and provinces he is satisfied. | Pattern of EliminationThe patient provinces he has a regular intestine motion daily. The patient denies jobs with diarrhoea or irregularity. The patient denies any jobs with micturition. The patient denies waking at dark to urinate. | Pattern of Activity and Exercise: The patient provinces since retirement. he has slacked on his day-to-day exercising. The patient states the lone exercising he gets is day-to-day yard work and horticulture. The patient states he used to take a stat mi long walk. but has slacked off of that. | Pattern of Sleep and Rest: The patient states he gets 7 hours of slumber every night.

The patient denies waking throughout the dark. | Pattern of Self-Perception and Self-Concept: The patient presents as a confident male who has uninterrupted oculus contact. | Summarize Your Findingss ( Use format that provides logical patterned advance of appraisal. ) | Situation ( ground for seeking attention. patient statements ) : The patient nowadayss today for a recheck of his mending scratch to right ear position station remotion of skin malignant neoplastic disease. | Background ( wellness and household history. recent observations ) : The patient states he has a history of several skin malignant neoplastic disease musca volitanss that have been antecedently removed. The patient states his female parent passed off from lung malignant neoplastic disease and his male parent with encephalon malignant neoplastic disease. The patient denies drainage or environing inflammation to country. The patient states he applied antibiotic unction every bit good as a dressing twice daily. | Assessment ( appraisal of wellness province or jobs. nursing diagnosing ) : The patient has a mending scratch noted to right ear. This scratch is free of drainage or inflammation. Nursing Diagnosis: Hazard for infection related to scratch to right ear ( Gulanick & A ; Myers. 2007 ) . | Recommendation ( diagnostic rating. follow-up attention. patient instruction learning including wellness publicity instruction ) : The patient needs to go on to use the antibiotic unction every bit good as dressing to the ear twice daily. The patient needs to go on to detect the country for drainage. inflammation. or marks of infection. The patient needs to go on to inspect his tegument for countries that may be leery for extra tegument malignant neoplastic disease lesions. The patient is educated on proper hand-washing accomplishments every bit good as marks of febrility or unwellness. The patient is besides educated on the importance of follow up with his skin doctor. | *

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Mentions

Gulanick. M. . & A ; Myers. J. ( 2007 ) . Nursing attention programs: Diagnosis. intercessions. and results. ( 6th ed. ) . St. Louis. Show me state: Elsevier Mosby.

Jarvis. C. ( 2012 ) . Physical Examination & A ; Health Assessment ( 6th ed. ) . St. Louis. Show me state: Elsevier Saunders.