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Nrs-434v Health Assessment of Older Adult

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Health History and Examination

Student Name: J.M | Date: May 31, 2015 | * Client/Patient Initials: C, M | Sex: F | Age: 63 | Occupation of Client/Patient: Retired Plant Operator | Health History/Review of Systems(Complete and systematic review of systems) | Neurological System:Client testifies that she has suffered migraines since puberty. Denies any head injuries, dizziness or convulsions. Visualized a small essential tremor in bilateral hands. States has some weakness, tingling, and numbness in both lower extremities due to bilateral knee replacements. Denies signs or symptoms of difficulty speaking, or swallowing. States takes Narcotic pain medications for pain management. | Head and Neck:States intermittent migraines. Denies any neck pain. Denies any abnormal lumps or swelling in her neck or head area. Sinus surgery in 1991, without complications. | Eyes:Denies eye pain, excessive tearing or blurred vision of the eyes. Last eye exam was March, 2014 which included glaucoma testing, vision testing. No visible redness of eyes. Client states she is currently wearing progressive lens glasses. States when eyes are occasionally dry she uses artificial tears. | Ears:Denies earache or other ear pain. History of childhood chronic ear infections. No lengthy exposure to loud environmental noises. Denies any vertigo or ear medications. | Nose, Mouth, and Throat: States has had cold sores of the mouth in the past. Denies any nosebleeds. States has had gingivitis in the past and was treated by dentist. Allergies to multiple medications and bee stings. Last dental check-up, states was 1 year ago. States has had many root canals and tooth implants. Rinses with medicated mouth wash. States had sinus surgery in 1991, with no complications. | Skin, Hair and Nails:Skin dry and intact. No signs of skin disease. Denies any changes in

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