RUA Health History and Physical Assessment
\nYour Name (without credentials)
\nChamberlain University College of Nursing
\nCourse Number: Course Name
\nName of Instructor
\nAssignment Due Date<\/p>\n
RUA Health History and Physical Assessment
\nThe purpose of this paper is to provide a health history assessment of an individual. I have completed the assessment interview with a family member. I will use the initials V.T. to indicate the individual\u2019s name. This health history assessment will be divided into subjective and objective data. The subjective data will include the individual\u2019s demographic data, their personal view on health, their family health history, their personal health history, a review of body systems, their cultural views, their social views, and their access to necessary resources. The objective data will include a thorough head-to-toe physical examination.
\nHealth History Assessment
\nDemographic Data
\nV.T. is a 36-year-old Caucasian male. He lives in a ranch-style home in a small subdivision in the middle of rural farmland with his wife and no other family members. He currently works for a utility company. His primary language is English.
\nReason for Care
\nV.T. is currently seeking care for a simple wellness check-up. He is looking to have a head-to-toe assessment conducted to ensure there are no new concerns he needs to be aware of. V.T. stated, \u201cI am not experiencing any issues that I am concerned about, I am just due for a wellness visit\u201d.
\nPresent Illness
\nV.T. does not have any present illnesses. He stated, \u201cI am not sick or experiencing any unusual signs or symptoms\u201d. V.T. is not experiencing any hospital-acquired illness or complications.
\nPerception of Health
\nV.T. defined what he considered to be healthy and unhealthy. He stated, \u201cBeing healthy means eating a well-balanced diet, taking vitamins daily and exercising\u201d. He then described ways of being unhealthy. He stated, \u201csmoking is unhealthy, eating fast food is unhealthy, and drugs are unhealthy\u201d. When asked how he felt about his health in comparison to the standards he just provided, V.T. stated, \u201cI am pretty unhealthy\u201d.
\nV.T. does not feel as though he is very healthy. When asked what he would change about his health, V.T. stated, \u201cEverything! I feel like I am not a very healthy person. I tend to eat way too much junk food and in really large portions. Although I stopped smoking, I still currently chew tobacco which is not much better. The only standard I gave you that I consider to be unhealthy that I do not do is use drugs.\u201d V.T. does not have any current health goals. V.T. stated, \u201cI mean I would like to lose some weight but I just do not have the motivation to try to lose weight again\u201d.
\nPast Medical History
\nV.T. has a history of asthma. V.T. stated, \u201cI had asthma as a kid but I grew out of it\u201d. He also has a history of bronchitis. He stated, \u201cI get bronchitis almost every year during the winter\u201d. He typically receives an inhaler but only to use while during his bronchitis episode. V.T. also suffers from heartburn. He stated, \u201cI have to take Nexium to keep my heartburn away. If I forget to take my pill, my heartburn is really bad\u201d. V.T. did not report any additional medical history or other disorders and diseases.
\nV.T. is not currently on any prescription medications. He stated, \u201cThe only thing I take is a Nexium pill every morning for heartburn\u201d. The only known allergies V.T. has is to shellfish. V.T. stated, \u201cI do not think I have any allergies to medications. I just ca not eat seafood or my throat will swell up\u201d. V.T. stated, \u201cMy mom had me vaccinated as a kid and I received whatever vaccinations were necessary when I enlisted in the National Guard. I do not get flu shots or any booster shots\u201d. V.T. had no surgical history. His wisdom teeth were removed, but they were not impacted and did not require him to be sedated.
\nFamily Medical History
\nV.T.\u2019s mother has COPD and Type 2 diabetes, high blood pressure, and high cholesterol. M.L\u2019s father does not have any known medical conditions. V.T. has two sisters. He stated, \u201cAs far as I know, neither one of my sisters suffer from any known medical issues\u201d. V.T.\u2019s grandparents on his father\u2019s side are not biologically related. M.L\u2019s father was adopted and he has not given any information on his biological parents. V.T.\u2019s grandparents on his mother\u2019s side are biologically related and have several medical conditions. V.T.\u2019s grandmother has Type 2 diabetes, high blood pressure, and high cholesterol. His grandfather also has Type 2 diabetes high blood pressure and high cholesterol. He also had triple bypass surgery about 8 years ago. Around the time V.T.\u2019s grandfather had his bypass surgery; he was diagnosed with prostate cancer. His prostate was removed and he has not been diagnosed with any other cancers.
\nReview of Systems
\nThe review of V.T.\u2019s systems was not a physical assessment. This part of the interview is V.T.\u2019s responses to questions asked about each system. He has provided past and current information on these systems.
\nReview of Head
\nV.T. is not currently experiencing frequent or severe headaches. He only suffers from an occasional headache that is easily resolved with an over the counter medications. V.T. has suffered from past head injuries. V.T. stated, \u201cI played football in high school and had a few concussions from that. I also did MMA for a little while and during my first fight, I got a concussion\u201d. V.T. has not recently experienced any head injuries and does not experience dizzy spells.
\nReview of Eyes
\nV.T. has moderate acuity difficulty and astigmatism that requires him to wear contacts daily. V.T. stated, \u201cSometimes I experience blurry vision but that is only if my contacts are starting to wear out and I need to replace them\u201d. V.T. does not experience blind spots, double vision, redness, swelling, excess watering, or discharge. Occasionally V.T. experiences eye pain. He stated, \u201cMy eyes hurt if I am wearing a pair of contacts and there is a rip in one of them and I can not replace it\u201d. V.T. does not have a history of glaucoma or cataracts.
\nReview of Ears
\nV.T. does not have frequent or severe ear infections or earaches. V.T. stated, \u201cI do not have a lot of problems with my ears. I have just noticed that I do not like to listen to music as loud as I use to\u201d. V.T. does have a history of tinnitus. He stated, \u201cI typically have daily ringing in my ears but it usually does not bother me. Every so often, the ringing will be really bad and I will have to close my eyes tight to make it go away\u201d. V.T. believes it could be from listening to loud music and hearing gunfire while serving in the army. V.T. does not have a history of vertigo.
\nReview of Nose
\nV.T. stated, \u201cI get sick pretty often during the winter but it is never severe\u201d. He does experience nasal congestions often due to a presumed deviated septum. V.T. stated, \u201cI have had my nose broken several times either from sports or getting into a fight. My nose has not been completely right ever since\u201d. V.T. does not have excessive nasal congestions, just during winter illnesses. He does not have a history of nosebleeds. V.T. stated, \u201cI have had a couple of nosebleeds that were not from being hit, but I think it was because the air was really dry and it irritated my nose\u201d. V.T. does not have a history of allergies. He has also not experienced a change in his sense of smell.
\nReview of Mouth
\nV.T. has a history of cavities. He stated, \u201cI do not like going to the dentist so I do not go unless my teeth hurt\u201d. V.T. has had his wisdom teeth removed as well as one molar. He stated, \u201cI had my molar removed after I cracked it on a popcorn kernel\u201d. V.T. does not have gingivitis, however, he does use chewing tobacco. V.T. did have an abscess on his tongue several years ago. V.T. stated, \u201cI bit my tongue and I couldn\u2019t stop messing with it so I think it got infected. I accidentally bit down on the sore and it popped. After it popped and all the stuff came out of it, it started to heal\u201d. V.T. has not had any other lesions on his tongue since. V.T. does not experience mouth pain and has had no change in his sense of taste.
\nReview of Throat
\nV.T. does not have difficulty with swallowing. He also does not experience frequent sore throat or hoarseness. He stated, \u201cThe only time I have a sore throat is when I am sick, especially if it\u2019s a sinus infection\u201d. V.T. has not had his tonsils removed.
\nReview of Heart
\nV.T. does not have a history of heart conditions. He does not experience frequent chest pains, tightness of the chest, or difficulty breathing while lying down or sleeping that is associated with a heart condition. He stated, \u201cI get short of breath while being active but that is just because I am out of shape. And the only time I have difficulty breathing while I am sleeping is from nasal congestion when I am sick\u201d. V.T. does not have a history of heart murmurs or any other abnormal heart sounds. He does not have a history of hypertension, coronary heart disease, or anemia.
\nReview of Lungs
\nV.T. does have a history of asthma. He stated, \u201cI had asthma as a kid but I grew out of it\u201d. V.T. does have a history of bronchitis and still has episodes of it during the winter. He does not have a history of emphysema, pneumonia, or TB. V.T. does not typically experience chest pain with breathing. He stated, \u201cI only feel short of breath if I am doing an intense workout\u201d.
\nReview of Skin
\nV.T. does not have a history of eczema, psoriasis, or hives. He has not noticed any abnormal changes to his skin tone or changes to any moles. V.T. does experience excessive dryness during the winter season. He stated, \u201cIn the winter my skin dries out pretty bad. I notice it mostly on my face and head. It gets pretty itchy and nothing seems to make it better\u201d. V.T. does not typically experience excessive itching when his skin is not dried out from the winter season. He has not experienced abnormal bruising, rashes, or other marks on his skin.
\nReview of Chest
\nV.T. does not experience chest pain. He stated, \u201cI only feel short of breath or any kind of chest pain if I am doing an intense workout. And I have not worked out in quite a while\u201d. V.T. has not noticed any lumps around his chest area and does not experience nipple discharge. He has not experienced any rashes over his chest.
\nReview of Peripheral Vascular
\nV.T. does not experience any coldness, numbness, or tingling in his legs or arms. He has not noticed any unusual swelling in his legs or feet. V.T. stated, \u201cI have not noticed any changes in color to my hands or feet. They are the same color as the rest of my body\u201d. V.T. has not experienced varicose veins, intermittent pain in his calves, or ulcers on his arms, legs, or feet.
\nReview of Abdomen
\nV.T. has not experienced any recent change to his appetite. He stated, \u201cThe only time I can think of that my appetite will change is when I am sick. I usually do not have much of an appetite if I do not feel good\u201d. V.T. does have an intolerance to shellfish. He stated, \u201cI use to be able to eat shrimp when I was younger but one day, I was eating it and my throat started to itch and swell up. I have not been able to eat it ever since\u201d. V.T. does have frequent heartburn. He takes over the counter medication to treat his heartburn. V.T. does not frequently experience abdominal pain, nausea, or vomiting. He stated, \u201cThe only time I feel abdominal pain is when I eat too much food or if I am sick. And I only get nausea or vomit if I am sick\u201d. V.T. does not have a history of abdominal disease. He does have regular bowel movements. V.T. stated, \u201cI typically poop once a day in the morning and they look normal to me\u201d. V.T. does not have rectal bleeding. He has not recently experienced any changes in his urination. V.T. did experience pain while urinating when he had a kidney stone. He stated, \u201cI felt pain around my back when I was trying to pass that kidney stone\u201d. V.T. does not have a history of any urinary disorders.
\nReview of Musculoskeletal
\nV.T. does not have a history of arthritis or gout. He does not have any joint pain, stiffness, swelling, or deformities. V.T. stated, \u201cI have hurt my shoulder before when I was lifting weights but I did not lose any range of motion from it\u201d. V.T. does not typically hear any noises when moving his joints. He does not typically experience muscle pain, cramps, or weakness. He also does not have an abnormal gait. V.T. does not have any issues with coordination activities. V.T. stated, \u201cThe only muscle problems I have are lower back pain. I hurt my back when I was younger helping my dad with some construction work\u201d. V.T. has not had any recent injuries to his joints, muscles, or back.
\nReview of Neurological
\nV.T. does not have a history of seizures, strokes, fainting, or blackouts. He also does not have any weakness, tics, tremors, or paralysis problems. V.T. stated, \u201cI do not have any numbness or tingling issues\u201d. V.T. also does not suffer from any memory loss disorders, depression, or other mental health disorders.
\nDevelopmental Considerations
\nErik Erikson, a well-known psychoanalytic theorist, theorized that all individuals progress through life in stages. V.T. is currently in his early adulthood. Erikson believed, \u201cthe central crisis of early adulthood is intimacy versus isolation\u201d (Boyd & Bee, 2015, p. 350). This means that during this stage of life, V.T. should be establishing a life-long intimate relationship with another person. If V.T. has not established this relationship, he will be faced with isolation.
\nV.T. is married and has been with his wife for almost 9 years and married for almost 4 years. He stated, \u201cI feel like I have met all of my adulthood milestones. I am married, I have a career, I own my own home, and can support myself and my wife\u201d.
\nCultural Considerations
\nV.T.’s parents were both raised Catholic but they did not raise him or his sisters under Catholic practices. He stated, \u201cI do not practice any specific religions. I also do not have any specific values or beliefs that I practice\u201d.
\nPsychosocial Considerations
\nV.T. is close to some of his immediate family. He stated, \u201cI am very close to my dad. I would consider him to be one of my best friends\u201d. He visits his parents at least twice a month. As of recently, V.T. is not close to either of his two sisters. He tries to keep in contact with some of his extended family and does so primarily through social media.
\nV.T. has several close friends. He is currently neighbors with his long-time childhood friend who he spends time with weekly. V.T. stated, \u201cI have a handful of good friends but one I would consider my best friend. We have known each other forever\u201d. V.T. stays in contact with is other friends at least a few times a month either by texting or social media.
\nV.T. has one specific social activity he enjoys doing. He is an active bow shooter and enjoys going to bow shoots. V.T. often goes to these bow shoots with his best friend. He stated, \u201cIt is a fun activity that we like to do together\u201d.
\nV.T. is not currently feeling stressed. He stated, \u201cI do not have anything to be stressed about right now\u201d. When V.T. is feeling stressed, he shoots his bow or hangs out with his dad or his best friend. V.T. often engages in the activities he enjoys and finds relaxing. He stated, \u201cOn the weeks I have downtime to be able to do the activities I like\u201d.
\nCollaborative Resources
\nV.T. stated, \u201cMy wife, parents, and friends are my main support system. They help me get through any tough times I have\u201d. V.T. does not attend church or any support groups. He has access to any resources he needs and they can easily be found within his community. Although he lives in a small rural area, he is not more than 10 minutes from a local grocery store. V.T. does not have a primary physician. He stated, \u201cAny time I need to see a doctor, I go to the local urgent care and get the medical help I need\u201d. V.T. does not attend a gym but he has access to a local gym in his community and a gym near his place of work. V.T. has access to many local grocery stores. V.T. stated, \u201cI have a reliable vehicle of my own that I can use to drive to any of the resources I need\u201d.
\nPhysical Examination Assessment
\nHead
\nUpon inspection, V.T. does not have any lesions or infestations. With palpation, V.T. does not have any abnormal bumps or tenderness. V.T. can clench his jaw without any notable pain or tenderness. V.T. can indicate the presence of a gentle touch of a cotton ball to his face with his eyes closed. This indicates cranial nerve V is intact. V.T. can smile, frown, scrunch his face, and puff up his cheeks. This indicates cranial nerve VII is intact. V.T. was able to press his face against my hand and shrug his shoulders when instructed. This indicates cranial nerve XI is intact. V.T. did not show any pain or discomfort when rotating his head.
\nEyes
\nUpon inspection, V.T. does not have any eye discharge or redness. His conjunctiva is pink and moist and his sclera is white and clear. V.T.\u2019s pupil size is 4mm, which is within the normal range. Utilizing a penlight, V.T.\u2019s eye pupils were equal, round, reactive to light consensually, and presented with accommodation. V.T. was able to follow the six cardinal fields of gaze indicating cranial nerves III, IV, and VI are intact.
\nEars
\nUpon inspection, V.T. does not have any lesions or piercings. V.T. does not have any pain or tenderness on palpation. No discharge is present. V.T. was able to repeat back all works whispered during the Whispered voice test. This indicates cranial nerve VIII is intact.
\nNose
\nUpon inspection, V.T. does not have any lesions. His nose is slightly asymmetric. V.T. does have a slight deformity, a deviated septum to the left. There is currently no inflammation or drainage present. V.T. as unilateral patency on the right as his deviated septum cause a slight obstruction on the left side. V.T. was able to identify the fragrance of coffee indicating cranial nerve I is intact.
\nMouth & Throat
\nUpon inspection, V.T.\u2019s lips, tongue, and gums are pink and moist. V.T. was able to swallow a sip of water. When asked to stick out his tongue and say \u201cAh\u201d, V.T.\u2019s uvula and soft palate both raised. This indicates cranial nerves IX and X are intact. V.T. was also able to stick out his tongue and move it from side to side and press against a tongue depressor indicating cranial nerve XII is intact.
\nNeck
\nUpon inspection, V.T.\u2019s trachea is midline. Palpation indicated no masses. The lymph nodes were not palpable which a normal finding is. M.L\u2019s thyroid gland was not enlarged or tender.
\nRespiratory System
\nUpon inspection, V.T. is breathing easy and even. There is no use of accessory muscles. V.T.\u2019s lungs were auscultated using the diaphragm of the stethoscope anteriorly in 5 positions. This was done so in a Z-pattern. V.T.\u2019s lungs were auscultated using the diaphragm of the stethoscope posteriorly in 6 positions. This was also done in a Z-pattern. All lung fields were clear.
\nCardiovascular System
\nUpon palpation, V.T.\u2019s carotid pulses are a regular rate and rhythm, 2+ bilaterally. With V.T.\u2019s laying at a 45-degree incline and head turned to the left, there is no indication of JVD. V.T. does not present with signs of edema. V.T.\u2019s heart was auscultated using both the diaphragm and bell of the stethoscope. This was done in five specific locations. No murmurs or abnormal sounds were heard.
\nGastrointestinal System
\nUpon inspection, V.T.\u2019s abdomen is symmetric with a round contour. V.T.\u2019s bowel sounds were auscultated for a full minute starting at the right lower quadrant to the right upper quadrant, left upper quadrant, and left lower quadrant. No abnormal bowel sounds were present. V.T.\u2019s abdomen was lightly palpated in the same order. No tenderness or distention was present.
\nMusculoskeletal System
\nUpon inspection, V.T. does not have any redness or abnormalities of his major and minor extremity joint sites. The joints appear symmetric with no abnormal contour. V.T. was able to conduct a full range of motion in each major and minor joint site and was able to indicate muscle strength by pressing back against resistance. V.T. does not present with an abnormal gait.
\nPeripheral Vascular System
\nV.T.\u2019s radial pulses are a regular rate and rhythm, 2+ bilaterally. V.T.\u2019s dorsalis pedis and posterior tibialis pulses are also a regular rate and rhythm, 2+ bilaterally.
\nNeeds Assessment
\nAfter completing V.T.\u2019s head-to-toe assessment and physical examination, I would advise additional health education on weight loss and tobacco cessation. A negative factor that may impede V.T.\u2019s ability to incorporate the health teachings into his daily living is he does not have the self-motivation to develop a plan and stick to it. Two positive factors would promote V.T.\u2019s ability to incorporate health teachings into his daily living. One is V.T. has a strong support group, his wife, and his parents. Another positive factor is V.T. has the necessary resources within his community and can access them daily.
\nV.T. is currently overweight. He discussed in his health assessment that he feels unhealthy and would like to lose weight but does not have the motivation to try again. By providing V.T. with additional education on the best approaches to losing weight, it will help him be more successful.
\nWeight loss is accomplished by eating a quality diet, drinking adequate water, and performing the appropriate workout regimen. To be successful, an individual needs to develop a plan. The planning should mainly consist of meal preparation. By preparing meals for several days, it helps reduce poor eating habits (Tufts University, 2018). If V.T. can develop a meal plan and follow through with meal preparation, he would be more successful in eating a balanced diet and avoid eating junk food that has added to his weight gain. The barrier V.T. faces primarily is self-motivation. However, his support system can continue to encourage his efforts to lose weight by following a meal prepping plan.
\nV.T. is currently using chewing tobacco. Although V.T. stopped smoking cigarettes years ago, the use of tobacco smoke is also damaging to his body. V.T. acknowledges that chewing tobacco is also unhealthy but does not have the motivation to quit. By providing V.T. with additional education on the negative effects chewing tobacco has on the body, it will help him be more successful in quitting.
\nUtilizing chewing tobacco as an alternative to smoking is not beneficial. Although chewing tobacco does not introduce toxic smoke to the lungs, it still harms the body. \u201cThe International Agency of Research on Cancer has concluded that there is sufficient evidence of carcinogenicity for smokeless tobacco\u201d (Wyss et al., 2016). If V.T. continues to use chewing tobacco, he is at higher risk for cancer. Providing him with education on the risks may help him to quit chewing. The primary barrier V.T. is self-motivation. However, his family is a strong supporter to encourage his cessation of chewing tobacco.
\nReflection
\nTo ensure a successful interview, I planned to interview at a time that was most convenient to the interviewee. I decided to interview in a quiet room with no other individuals present. The afternoon was the best time of day to conduct the interview, so I had everything prepared before the afternoon. I utilized therapeutic communication techniques, such as active listening and empathy, throughout the interview (Jarvis, 2020). Active listening encourages the interviewee to speak because they feel acknowledged. Empathy allows the interviewer to connect with the interviewee on a more personal level.
\nThe interview process felt more comparable to what was learned in class because we not only assessed the individual\u2019s health, we performed a physical examination. This interview process helped bring everything learned in health assessment together.
\nFor the most part, the interview went well. I did not have any notable barriers to overcome during the interview. The individual I interviewed on is a family member so he was not uncomfortable with sharing his health history with me or allowing me to perform a physical examination on him. I did my best to keep the interview professional but without making the individual feel uncomfortable. I avoided using professional jargon, medical terms, that the individual would not know. Using professional jargon is considered one of the interview traps that should be avoided (Jarvis, 2020). Since I did not have any barriers to overcome, I would not change any part of the interview for the future.
\nThere were no unanticipated challenges during the interview. I had a list of questions prepared to ask the interviewee before beginning the interview. I wanted to make sure I covered all the required areas. The interview went smoothly and there were no issues to notate.
\nI did not find there to be any information that I wish I would have had available to me that I did not. Again, I had all the questions I needed to be prepared before the interview. My interviewee was cooperative and answered all the questions I asked.
\nIn the future, I would like to adjust the questions that I ask. The questions I asked were fairly standard. I think if I adjusted the questions to be more guided to that individual, I may get more information. I also need to continue to work on building a rapport with my interviewee since I will not always be conducting interviews on individuals I know personally.<\/p>\n
References
\nBoyd, D., & Bee, H. (2015). Lifespan development (7th ed.) [VitalSource bookshelf version]. Retrieved from https:\/\/online.vitalsource.com\/#\/books\/9781323031223\/cfi\/6\/2!\/4\/2@0:16.6
\nJarvis, C. (2020). Physical examination and health assessment (8th ed.) [VitalSource bookshelf version].
\nTufts University. (2018). Weight loss: No quick fixes. Tufts University Health & Nutrition Letter, 36(1), 3. https:\/\/www.nutritionletter.tufts.edu\/healthy-eating\/weight-mgmt\/weight-loss-no-quick-fixes
\nWyss, A. B., Hashibe, M., Lee, Y. A., Chuang, S. C., Muscat, J., Chen, C., Schwartz, S. M., Smith, E., Zhang, Z.F., Morgenstern, H., Wei, Q., Li, G., Kelsey, K.T., McClean, M., Winn, D. M., Schantz, S., Yu, G. P., Gillison, M. L., Zevallos, J. P., Boffetta, P., & Olshan, A. F. (2016). Smokeless tobacco use and the risk of head and neck cancer: Pooled analysis of US studies in the INHANCE consortium. American Journal of Epidemiology, 184(10), 703-716. https:\/\/doi.org\/10.1093\/aje\/kww075<\/p>\n","protected":false},"excerpt":{"rendered":"
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