Health History Review Of The Systems English Literature Essay

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Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves

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Health History/Review of Systems

(Complete and systematic review of systems)

Neurological System:

No history of any head injury. She does have a history of migraines dating back to the age of 12.She states that they are frontal or parietal in nature. She has on a rare occasion had bouts of dizziness these have occurred when she has been sitting or lying down for periods of time and stands up too fast. She has a diagnosis of a cardiac compensation dysfunction which she takes medications for. She denies having a history of seizures, numbness or tingling, or any problems with talking or swallowing.

Head and Neck :

Mrs. S does have a history of neck pain of 12 years. This started shortly after she was moving a patient and he grabbed her by the neck. She takes Tylenol migraine for the pain and uses a heated neck bean bag pillow. She has never had surgery for this but has had surgery at the base of her neck for thyroid excision. She takes synthroid for hypothyroidism.

Eyes:

Mrs. S. has been wearing glasses ever since she was in the first grade. She stated that she is happy that they have the new composite lens as she used to have to wear glasses with lens that were ¼ inch thick and they were very heavy on her nose. She now wears glasses or contacts daily without them she states she is legally blind. She does not have astigmatism, strabismus, but does have a family history of glaucoma. For this reason she is not able to get LASIX treatment for her eyes. She does have a history of seasonal allergies that affect her and she takes prescription medication for this. She has and appointment with her optometrist every year and at that time she gets a new pair of glasses or boxes of contacts. She is an avid reader and reads a normal print size with her glasses. She has been diagnosed by her optometrist with a partially detached retina and says that she has floaters in her visual field.

Ear:

Mrs. S says that she does not get earaches but as a child she used to be a regular at the pediatrician for ear infections. "At one point they were going to put in myringotomy tubes but changed their mind". She doesn't believe that she has any hearing deficit but says that her husband says she does not hear as well as she used to and asks her to turn the volume down on the television. Her father wears bilateral hearing aids and has had poor hearing since his forties. She denies any form of environmental noise pollution but then says her husband can hear her car coming down the street from her turned up radio. About 4 years ago she did have a problem with tinnitus that lasted just under 2 years in duration. She uses ear drops and a q-tip to clean her ears out on a regular basis making sure not to go too far into the ear canal.

Nose, Mouth, and Throat:

At the current time Mrs. S has no nasal discharge, she says that she uses gets a cold 1-2 times a year that last 1-1 ½ weeks. She still has her tonsils and rarely has a sore throat. She has environmental allergies to pollens and takes oral medications seasonally. She sees her dentist at least biannually and has a clean bill of health from the dentist. She brushes her teeth twice daily using a pulsating toothbrush.

Physical Examination

(Comprehensive examination of each system. Record findings.)

Neurological System: (Cranial Nerves)

Olfactory Nerve: Both nares are clear as shown by no difficulty with inhalation and exhalation as the opposing nare is blocked. When different scents are tried she is able to states smell is equal bilaterally.

Optic Nerve: While she is wearing corrective glasses visual test was done and she had equivalent vision in both eyes. She has a slight separation of the left retina; otherwise the color and shape are within normal.

Oculomotor, Trochlear, and Abducens nerves: Pupils are equal and reactive and pupils are 5 mm in size. She has no nystagmus. She passed the trochlear and Abducens tests

Trigeminal Nerve:She has equal muscle development of the temporal and masseter muscles as felt during palpation. She has good jaw strength. When tested for sensory function she had equal sensation of ophthalmic, maxillary, and mandibular on the left and right hemispheres.

Facial Nerve: Mrs.shows normal mobility and facial symmetry when she was asked to smile, frown, puff cheeks, and lift eyebrows.

Acoustic Nerve:Several different tuning forks with different pitches with an equal conduction bilaterally. She had some difficulty with the whisper test right ear hearing is better than the left.

Glossopharyngeal and Vagus nerves:Motor function was normal when tested using a tongue depressor and having her say ahhhh; she also has a very strong gag reflex. No abnormality with vocalization.

Spinal Accessory Nerve:She has equal strength when tested using shrug and head rotation resistance test. Her trapezius and sternomastoid muscle are equal upon visualization.

Hypoglossal Nerve:No tremors of the tongue when inspected, lingual speech distinct

Head and Neck:

Mrs. S has a normocephalic skull with no discomfort upon palpitation. A pulse was felt bilaterally of the temporal artery and it was of equal amplitude and rate. The facial bones are equal left and right. There was no clicking or catching felt as her mandible was opened and closed. The accessory muscles of the neck show equal development on both sides. The head has equal movement when rotated left and right, chin is able to touch her chest, and she has good extension. No visualization of the carotids are seen. Lymph nodes were palpated with no enlarged or tender nodes being found. Trachea is midline no discomfort, during palpitation thyroid size normal no enlargement felt and no bruit heard upon auscultation.

Eyes:

Mrs. S has reported poor vision when not corrected by glasses or contacts as her vision is 20/200 correctable to 20/20. She has good tracking ability. Her eyebrows, eyelids and eye lashes are within the excepted range. Eyes are equal distance from the center and set in the eye socket well. Her sclera is clear and the internal skin of the eyelids are pink without any lesions or petechiae. The eyes are moist without too much tear production. The iris is normal for shape and size with good light reaction. No cataract development. The optic fundus appeared normal although Mrs. S did state that she has a partially detached retina which I did not see.

Ears:

Her ears are located well with equal size bilaterally. There are no visual malformations skin color is consistent. She has no complaint of discomfort when ears are manipulated. The inspection of the external auditory meatus shows no cerumen build-up. The inspection of the ear canal shows minor cerumen no redness or inflammation of the ear canal. The right ear has some build-up of cerumen on the tympanic membrane while the membrane on the right appears normal with no bulging or discoloration. Whisper test, and air conduction tuning fork tests does show some decline in hearing on the left side although she did well with the bone conduction test. The Weber test shows no difference in either ear.

Nose, Mouth, and Throat:

Mrs. S has a nose that is midline on her face and is in proportion to the other facial structures and skull size. There is no visual sign of any past trauma to the nose and feels straight without any complaint of pain when palpated. She is able to breathe thru each nare without difficulty while the other nare was blocked. The internal aspects of the nasal cavity had a normal appearance without any infection, or abnormal discharge. It was moist with a healthy redness and no growths of polyps, turbinates' also appeared to be normal in appearance. She had no pain when the frontal and maxillary sinuses were palpated. Her lips were moist without any discoloration. The gums were pink without any plaques no swelling at the tooth line. Teeth appear well brushed and cared for. She is missing her 4 back molars which were taken out in her grade school years when she had braces. The tongue is moist without any patches or lesions. She does have a strong gag reflex as she began to gag during examination of the tongue. The base of tongue has no lesions. Her inner cheek is reddish and moist also with no visual or palpable abnormalities as is her palate. The tonsils are visible and are 1+ in size. Uvula shows good rise when she says ahhhh. The throat shows no signs of infectious process with a light reddish color, no exudate or lesions.

FHP Assessment

Cognitive-Perceptual Pattern:

Mrs. S is an articulate person with no obvious cognitive deficits. She has her bachelor's degree in education and nursing. She is an avid reader stating that there is a history of Alzheimer's dementia in her family and believes she needs to keep her mind challenged.

Nutritional-Metabolic Pattern:

Her diet is poor, usually eating TV dinners, and diet sodas. She does have a couple servings of yogurt daily to help her digestive season and to help with preventing yeast problems. She does not cook at home and relies on her husband for any cooking. She has a plan to go on a diet related to her blood type to shed the weight she has gained during her marriage. She has no diabetes or any other metabolic disease.

Pattern of Activity and Exercise:

Mrs. S says that she gets most of her exercise working as a nurse and is usually too tired after work to do any exercise. She has fad joining's of health clubs usually making it 2-3 months before giving up. She is currently >30 pounds overweight and knows that her weight is detrimental to her health but states that she has no energy to exercise. She socializes with friends from work and likes to go to movies with her family.

Pattern of Sleep and Rest:

Mrs. S says she loves to sleep getting 8 hours of sleep nightly and she is able to take 2-3 hour naps on her days off. She does take a sleeping pill at night. She does appear to be well rested. She said that she takes a sleeping pill because she gets wound up during the evening part of her shift and this makes it hard for her to fall asleep.

Pattern of Self-Perception and Self-Concept:

She has a very good awareness and appears to be very comfortable with where she is in her current stage of life. She says that the only thing that she would change is her weight. She holds herself erect with no slouch while walking and during the interview. She also engages people when she communicates using a smile and has a light hearted air about her.

Summarize Your Findings

(Use format that provides logical progression of assessment.)

Subjective:

Mrs. S had no complaints of health problems prior to this history. She stated during the exam and interview that her husband thought her hearing had declined. She also said that she was overweight by >30 pounds and she has a history of migraines which she resolves with the use of medications. She also has a low energy level which hinders her from exercising in her attempt to lose weight. She takes medication for cardiac decompensating affect which she takes medications for.

Objective:

Mental Status:

She is alert and oriented times three, with appropriate behavioral and verbal responses to questions. She also passed the memory test.

Cranial Nerves:

Olfactory Nerve: Both nares are clear as shown by no difficulty with inhalation and exhalation as the opposing nare is blocked. When vanilla and coffee scents are tried she is able to states smell is equal bilaterally.

Optic Nerve: While she is wearing corrective glasses visual test was done and she had equivalent vision in both eyes. She has a slight separation of the left retina; otherwise the color and shape are within normal. Vision is 20/200 without glasses and 20/20 with in both eyes. All other visual tests normal.

Oculomotor, Trochlear, and Abducens nerves: Pupils are equal and reactive and pupils are 5 mm in size. She has no nystagmus. She passed the trochlear and Abducens tests

Trigeminal Nerve:She has equal muscle development of the temporal and masseter muscles as felt during palpation. She has good jaw strength. When tested for sensory function she had equal sensation of ophthalmic, maxillary, and mandibular on the left and right hemispheres.

Facial Nerve: Mrs.S shows normal mobility and facial symmetry when she was asked to smile, frown, puff cheeks, and lift eyebrows.

Acoustic Nerve:Several different tuning forks with different pitches with an equal conduction bilaterally. She had some difficulty with the whisper test, right ear hearing is better than the left.

Glossopharyngeal and Vagus nerves:Motor function was normal when tested using a tongue depressor and having her say ahhhh; she also has a very strong gag reflex. No abnormality with vocalization.

Spinal Accessory Nerve:She has equal strength when tested using shrug and head rotation resistance test. Her trapezius and sternomastoid muscle are equal upon visualization.

Hypoglossal Nerve:No tremors of the tongue when inspected, lingual speech is distinct

.

Head, Face and Neck: Normocephalic skull, trachea is midline, lymph nodes were not palpable, no enlargement of the hypothalamus. No deficits in side to side or extension of head movements. Face is symmetrical with no tremors.

Eyes: Sclera is clear with no excessive tearing. No nystagmus with tracking. Pupils are at 5mm and are round in shape. Eyes are equal and reactive. Inner make-up of eye normal with appropriate arterioles and venules. Eyebrows and lashes are even spaced and show normal function.

Ears: The whisper test showed a hearing deficit in the left ear. Her conduction tests were normal. She had cerumen built up over her right tympanic membrane. Otherwise internal ear exam was negative. Ears are equal size and place well on skull. No masses, lesions, discharge, or discomfort was found during exam.

Nose, Mouth and Throat:

Her nose is symmetrical on her face. No sign of any past injury and no septal deviation found during palpation. Nasal mucosa is normal in coloration and moist. No discharge seen.

She has no difficulty with biting down and has good strength. She is missing 4 molars that were taken out when she had braces. Teeth appear well brushed and gums are healthy. Tonsils present and1+ in size. Uvula rise is centered and gag response present.

No undue redness of the throat and no aversive exudate seen.

Assessment:

Overall Mrs. S is in good health with their being only one unaddressed problem that needs addressing. This is her hearing deficit of the right ear. All other issues she has are being addressed by her associated physicians. I will also at this time address her migraines as she does not appear to be taking her medicine correctly, and her partially detached retina as I believe there is room for further education in these areas.

Plan :

Mrs. S first needs to have her ears flushed out then have a repeat of her auditory ability to make sure she does not have any nerve damage of her right ear. She then needs to be re-educated in medicines used for the control of migraines. She may also need a CT scan of her head to make sure there is no organic reason for the migraines. She then may benefit from relaxation techniques as the stress from her job may be causing the migraines. As for her partially detached retina she needs reinforcement education as to what can exacerbate the condition. Examples of this being low key exercise that does not increase intraocular pressure especially since she is planning to go on an exercise and diet regimen to lose weight also protect her head from any form of trauma that may cause a worsening of the detachment.

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