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Head to Toe Video Assessment
Advance Health Assessment and Promotion
Elizabeth Copley
June 22, 2017
Subjective Data
The patient is a 55-year Caucasian female, a registered nurse that has presented for a complete physical today. This patient puts health first and is a great historian when it comes to her health. The patient does not have any physical complaints today but presents for her annual screening.
Patient has a history of a tonsillectomy in 1969, a hysterectomy in 2010, two vaginal deliveries uncomplicated, and a tubal ligation in 1996. She has no known drug allergies. Her current medications are Crestor 40mg, Citalopram 10mg, and Esgic 1 tablet, Estradiol 0.75mg, Zolpidem 5mg, and a Calcium D supplement.
The patient was adopted as an infant, so no family history is known. The patient was adopted by a Judge and his wife and has to adopted brothers as well. She is married and works as a registered nurse. She denies smoking but does report she smoked when she was younger socially. She also drinks socially and denies the use of illegal drugs. She does state that she has always eaten healthy, but now her diet is stricter due to her husband recently having a double by-pass and has to keep a diet that is low sodium, low fat, and low carbs. She has no problems with sleeping, walks in the evenings during nice weather and is an active Baptist.
Review of Systems
The patient is overall healthy, ideal weight, denies rash, freckles over chest and back, no scars or other lesions, nearsighted, wears glasses, no hearing problems, and teeth are all intact. No wheezing, coughing or shortness of breath, denies chest pain, palpitations or fast heartbeat. Patient denies nausea or vomiting, no constipation or diarrhea, muscle strength 5/5 in all extremities, and has a full range of motion in all joints. She is alert and oriented times 4, PERRLA, speech clear, and CN 1 –X11 intact, DTRs bilaterally 2+.
Objective Data
The patient is a well-developed, Caucasianfemale in no acute distress. Her weight is 115 pounds, and is 5’2”, Temp is 98.0, Pulse=72, BP=102/64, and Respirations=18 and non-labored. Her skin is pink, warm and dry, skin turgor normal, her eyes have no erythema of the sclera, pink conjunctiva, no drainage, eye exam normal with fundoscope, no difficulty with hearing, tympanic membrane pink, and with no drainage. Auscultated S1 and S2, no murmurs heard. Lungs are clear, respirations non-labored. Abdomen soft, non-tender, bowel sounds within normal limits, and no hepatomegaly or splenomegaly. Muscle strengths equal and strong in all extremities, with a full range of motion, gait normal. Speech clear, and CN 11-X11 intact, and DTR's2+ bilaterally.
Assessment/Plan
Annual assessment completed and no new problems were identified. The patient is scheduled for an appointment in three months for medication refill and to address any new problems. The patient is instructed to follow up sooner for any new symptoms or problems.
Rhoads, Jacqueline, and Sandra Wiggins Petersen. Advanced Health Assessment And Diagnostic Reasoning. Burlington, MA.: Jones & Bartlett Learning, 2014. Print.