Health & Medical Paper

a. Select a client to interview.

b. Obtain a complete history from the client and perform a complete physical assessment (no invasive assessment).

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c. Formulate diagnosis and possible treatment plan based on data collected.

d. Document the history and the assessment using a standard organized format, including genogram.

Subjective Data
Date: 08/22/2016
Patient’s Name: SB
Patient Sex: Female
Age: 28 years
Informant: Patient
Date of Birth: 06/30/1988
Occupation: Registered Nurse
Race: Black (Afro-Caribbean)
Insurance: Kaiser Permanente
Reliability: Reliable, good historian, detailed information
CHIEF COMPLAINT: Yearly Physical
Allergies: No known drug allergies
Immunizations: Reports all childhood immunizations received, as well as boosters. Does not
have records. Tetanus within past 5 years. HPV vaccine at age 23 years.
Past illnesses and hospitalizations: None reported
Current medications: No prescription medications, no supplements
INJURIES: Left arm fracture – May 1996
Birthplace: Los Angeles, California
Education: Bachelors in Nursing. No history of special education.
Religion: Devout Baptist.
Occupation: Registered Nurse in adult intensive care unit.
Hobbies: Sings in church choir, plays violin in city orchestra, volunteers for medical mission
trips with church and employer.
Travel: Travels out of country each year for vacation or to visit extended family.
Marital Status: Single, no significant relationships.
Financial Concerns: No financial concerns
Daily living habits and risks:
Type of housing and neighborhood safety: Homeowner, single family dwelling,
middle class neighborhood, low crime rate reported.
Others in household: Two young adult female roommates, both registered nurses.
Pets in household: No pets.
Use of smoke detector: Three smoke detectors which are checked twice per year
with time changes.
Use of CO detector: Two CO detectors which are checked twice per year with time
Use of seatbelt: Seat belt worn 100% of the time.
Substance Use: Caffeine: 1 cup per day Tobacco: None Alcohol: None
Illegal drug use: None.
Diet: Breakfast – coffee, breakfast burrito with egg, cheese, potatoes. Lunch –
spaghetti and turkey meatballs, broccoli. Dinner – restaurant, teriyaki chicken,
noodles, 2 vegetable spring rolls, mixed vegetables.
Exercise: Treadmill 30 minutes per day, stationary bike 30 minutes per day, jogging
1 hour per day 5 times per week. Tolerates each modality without difficulty or
Sleep habits: Sleeps 8-9 hours per night, no sleep aids, rare nocturnal arousals,
feels rested upon awakening, rare daytime sleepiness.
Father is 50 years old and described as healthy. Mother is 49 years old with history of diabetes
diagnosed 1 year ago. SB has 1 brother, age 26 and 1 sister age 24, both reported as healthy.
Maternal grandmother alive, age 76 has hypertension diagnosed at age 56, type 2 diabetes
diagnosed at age 50 and benign positional paroxysmal vertigo. Paternal grandfather, age 77,
alive with hypertension diagnosed at age 52 and gout diagnosed at 55. A paternal aunt age 56,
has type 2 diabetes, diagnosed at age 45.
Patient reports no family history of muscle disease, cancer, autoimmune disease, hematological
disorders, seizures, psychiatric disorders, or mental retardation. Denies family history of
Constitutional: Reports currently at usual weight and no recent history of weight loss or gain.
Denies any weakness or unexplained fatigue. Denies recent fever. Denies changes in mood.
Skin, hair and nails: Denies excessive hair loss, brittle nails, cold fingers or toes, easy or
excessive bruising, concerning skin lesions or rashes. Denies birthmarks.
Head and neck: Denies headache, dizziness or lightheadedness, swollen glands or neck
Eyes, ears, nose: Denies changes in vision, burning or itchy eyes, lesions on eyelids, difficulty
with hearing, ear pain or drainage, nasal congestion or drainage, nose bleeds, change in taste or
Throat and mouth: Denies difficulty swallowing, sores or pain in mouth or throat, cough, dry
mouth or excessive saliva. Reports dental exam with cleaning 4 months ago. Reports 3 wisdom
teeth extraction approximately 3 years ago.
Lymphatic: Denies any swollen lymph nodes or swelling of extremities.
Chest and lungs: Denies chest pain, history of asthma, shortness of breath, cough, bloody
Breasts: Denies any lumps, nodules or pain, nipple discharge, noticeable asymmetry. Reports
occasional self-breast examination.
Heart and blood vessels: Denies any palpitations, racing heart or skipping heart beats.
Denies history of elevated blood pressure or fainting.
Hematologic: Denies bruising, excessive bleeding or any history of hematological disease.
Hemoglobin not checked in at least 2 years. No history of blood transfusions.
Gastrointestinal: Denies constipation, diarrhea, nausea, vomiting, blood in stool,
gastroesophageal reflux. Denies abdominal pain. Does not have any dietary restrictions.
Diet: Reports normal diet, without restrictions. No food allergies.
Endocrine: Denies heat or cold intolerance, excessive weight gain or loss. Denies excessive
hunger or thirst.
Genitourinary: Reports menarche at age 12, with menses regular every 28-30 days and
lasting 4-5 days. No excessive or prolonged bleeding. Denies any genital lesions itching or
discharge. Denies being sexually active and does not use birth control. Denies history of pain
or burning on urination, urinary frequency or urge, nocturnal enuresis or daytime incontinence.
Denies hernias.
Musculoskeletal: Denies any muscle weakness, stiffness or pain, pain in joints or pain with
movement. Denies back pain.
Neurological: Denies headache, seizure activity, difficulty with memory, muscle weakness,
difficulty with speech or difficulty with balance. Denies tremors, tics or involuntary movements.
Denies numbness or tingling or decreased sensation, particularly in hands and feet.
Mental health: Denies current or history of anxiety, depression or any other alteration in
mood. Denies any psychiatric medications. Reports being happy and content with her life.
Denies any previous or current thoughts of suicide.
Physical Exam:
General Statement:
Temp: 97.4 HR: 72 RR: 18 BP: 113/70 Height: 5’ 4” Weight: 116 lbs. BMI: 19.9 – normal
Mental health: Cheerful, spontaneous speech. Alert and oriented to self, date and time,
place. Short and long-term memory intact.
Skin, hair, nails: Skin pink and warm to touch, no lesions, rashes or bruising noted. No
petechiae. Good skin turgor. Moist with exception of heels, which are dry. Scattered freckles
on upper back. No birthmarks. Nails pink, no clubbing or hyperpigmentation. Gums moist, with
some hyper-pigmented areas. Hair is evenly distributed and soft. No lesions or flaking noted
on scalp.
Head: Normocephalic, without evidence of trauma
Eyes: Evenly spaced, sclera white, no hemorrhage or lesions, conjunctiva pink, pupils equal,
round and reactive to light and accommodation, red reflex is seen bilaterally, fundus is sharp
bilaterally, visual acuity is 20/20 in left eye and 20/25 on right eye.
Ears: Normal placement, tympanic membrane pearly gray, no drainage, scant cerumen,
external canal patent. No sinuses observed.
Nose: Nares patent bilaterally, pink turbinate, no polyps, no drainage or congestion.
Throat and mouth: Tongue pink and non-enlarged, buccal mucosa pink and without lesions,
tonsils pink non-enlarged, and without exudates, uvula midline, no clefts in palate, wisdom
teeth absent, presence of one cavity in right lower molar, teeth aligned, pharynx pink with
small amount of drainage.
Neck: Supple, thyroid gland non-enlarged and no nodules, trachea is in midline. No
Chest: symmetrical without deformities, no lifts, heaves or thrills. Observed faint apical
Lungs: Clear and equal breath sounds in all lung fields, no crackles, rhonchi, wheezing or
shortness of breath. No cough.
Breasts: Normal breast exam
Heart: Regular rate and rhythm, S1 and S2 heard, no murmur.
Blood vessels: No varicose veins, palpable carotid pulse, no bruits, no jugular venous
Abdomen: Soft, flat, nontender, no pulsations, liver 1 cm below the right costal margin, no
hepatosplenomegaly, no masses.
Genitalia: Normal female genitalia
Anus and rectum: Normal exam
Lymphatic system: No lymphadenopathy or swelling of extremities
Neurological: Articulate with normal speech pattern, socially interactive, affect good.
Cooperates with exam and follows verbal commands.
Cranial nerve I: Intact to smell
Cranial nerve II: Funduscopic exam normal, no papilledema observed, visual acuity 20/20 left
and 20/30 right, peripheral vision intact.
Cranial nerves III, IV and VI: Extra-ocular movements intact without nystagmus, no strabismus,
no ptosis of eyelids observed.
Cranial nerve V: Temporal and masseter muscle strength and movement intact. Sensory exam
intact to light and dull touch. Corneal reflex present.
Cranial nerve VII: Face activates symmetrically, no facial weakness observed. There are no tics,
quivering or other involuntary movements noted.
Cranial nerve VIII: Hearing is intact to normal voice and whisper.
Cranial nerve IX and X: Soft palate elevates symmetrically, uvula elevates in midline, normal
medial movement of posterior pharynx, gag reflex is present.
Cranial nerve XI: Sternomastoid and trapezius muscle strength strong.
Cranial nerve XII: Articulate speech, tongue is of normal size and without atrophy, no
weakness or fasciculation observed, tongue protrudes in midline and moves freely laterally.
Muscle is good in bulk, tone and 5/5 in strength in all extremities.
Reflexes are 2+ in biceps, triceps, knees and ankles.
Coordination is intact on fine finger movements, rapid alternating hand movements, heel-toshin movements. Gait is narrow-based and age appropriate. She was able to walk on toes,
heels and perform tandem gait. She demonstrated negative Romberg test and no pronator
Laboratory and Diagnostic Studies: No recent laboratory or diagnostic studies.
Assessment Diagnosis: Well Adult Exam
1. Health Promotion: Recommend obtaining immunization records for evaluation. Further
recommendations after evaluating records.
Labs: CBC, CMP, Thyroid Studies, Total cholesterol, LDL, HDL, Triglycerides, Hgb A1C.
2. Exercise Recommendations: Continue with present exercise program as tolerated,
being sure to include a mix of aerobic and strength exercises.
3. Diet Recommendations: Reduce fast food intake, reduce dietary intake of cheese and
red meat.
Maternal Grandfather
Age 72
Maternal Grandmother
Age 71
Age 47
Age 26
Age 45
Age 50
Age 49
Age 24
Paternal Grandmother
Age 76
Paternal Uncle
Age 48
Age 28
type 2
Paternal Grandfather
Age 77
Paternal Uncle
Age 46
Paternal Aunt
Age 56

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