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Adulti Physical


Submitted By sexiarn
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Adult Health History and Examination RN
Health Assessment and Screening
NRS 434-V
Health History and Examinati
Client/Patienton Initials: LH Sex: F Age: 47
Occupation: Registered Nurse
Health History/Review of Systems
Neurological System headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, and difficulty swallowing etc., medication): Neurologically JP is intact. Alert ox3 clear speech with no hesitations, c/o headaches and dizziness occasionally, upon arising in the am. She admits being “little stressed to family situations” and rotating shifts (DAYS/NIGHTS). Suggested to seek EAP (Employee Assistance Program) at work
Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications: LH has full ROM to neck and head, closes her eyes and able to hold her arms and hands out without swaying. LH takes Motrin 800mg for headaches. Motrin (ibuprofen) is a no steroidal anti-inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. This medicine may also cause serious effects on the stomach or intestines, including bleeding or perforation (forming of a hole). These conditions can be fatal and can occur without warning while you are taking Motrin, especially in older adults. Nursing Drug Handbook (2013)
Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications: LH has myopia and astigmatism. She wears glasses for correction and contact lenses for aesthetics, no familial history of glaucoma, last eye exam on Sept 12, with no problems.
Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise

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