Healthy Patient’s History and Physical Assessment

Table of Contents

Subjective

Chief complaint: The patient does not have any major complaints.

History of Present Illness (HPI): A patient is a middle-aged man. He does not have any health issues. A general overview of his systems was conducted. The overview showed that the patient was healthy.

The patient’s past medical history does not contain any issues of major concern. He has not had any significant diseases or disorders. He does not have any known allergies. His family history does not contain any data that could be used to determine family-specific threats to his health. The patient’s psychosocial history also indicates that he is not prone to developing any psychological issues associated with communication problems (k33psimple, 2018).

Objective

General: The patient’s general physical appearance does not have any signs of health issues.

Skin: The skin has a uniform pink color with no dark or pale areas. There are no signs of edema or lesions. The patient’s hair can be deemed as normal, although it has signs of receding.

HEENT and Neck: the patient does not have any regular headaches. The sclera of the eyes is white, and the hearing is good. The throat does not have any abnormalities or signs of possible issues. The mouth is slightly dry; the patient does not have any complaints about pain in it.

Pulmonary: The anteroposterior diameter is within the norm.

Cardiac: HR 90 beats per minute. The patient’s rhythm is regular, and his S1 and S2 are within the acceptable range.

GI: The patient’s abdomen can be characterized as symmetrical and with no protrusions. The skin of the abdomen does not have any color abnormalities, lesions, or scars. The bowel sounds present. The patient’s liver span is also within an acceptable range.

Musculoskeletal: no splittings have been observed during the examination. The patient’s neck has full ROM; furthermore, the patient did not have any complaints concerning neck pains or unpleasant sensations in the specified area.

Peripheral Vascular: The patient does not have any swelling, the feeling of tightness, or any other sensations that could signify the presence of a peripheral vascular issue.

Neurologic: The patient’s speech and appearance indicate that he does not have any neurologic disorders, either.

Review of Systems

HEENT and Neck: The patient does not have any complaints regarding neck pain or headache. The patient has a good sense of smell in both nostrils. His eyesight is also good. The distance test revealed no deviations from the norm, therefore, allowing assuming that the patient’s eyesight is in perfect condition. The patient’s ears and throat were also in good condition, with no evident negative tendencies observed. The patient does not have any pain in his mouth, either; bleeding gums and toothache was not registered, either.

Pulmonary: The patient’s lungs function properly. He does not have any complications breathing. Similarly, no cough or any other signs of respiratory issues were observed during the examination.

Cardiac: The heart rate was defined as average. The patient does not have any cardiac concerns.

GI: the patient does not have any complaints regarding his digestive system. No issues associated with GI were registered during the examination of the patient. The latter did not voice any problems concerning his appetite; similarly, no weight problems were identified in the course of the examination.

Musculoskeletal: There are currently no issues associated with the musculoskeletal system. The patient does not have muscle pain or stiffness. Furthermore, no motion limitations or joint pain were observed during the examination process. The patient does not have any bone traumas.

Peripheral Vascular: The patient’s skin is of an even and regular color. The lymph nodes of the patient are in check, and no swellings, stiff areas, or areas with a different skin tone were identified during the examination. The patient does not have any symptoms of obesity. Similarly, no diabetes or related problems were identified in the process.

Neurologic: The patient does not experience any fatigue or weakness. There have been no mental health concerns or similar experiences in the patient’s life. The patient’s speech is flowing and uninhibited.

Problem List

At present, no problems regarding the patient’s well-being can be observed. All systems function properly, and no threats to the patient’s well-being have been identified. Therefore, sustaining the current positive condition must be deemed as the top priority.

Despite the absence of any evident problems, it is crucial to establish a tighter connection between the patient and a nurse. Thus, the possible development of health problems can be avoided successfully.

Plan

It is strongly recommended to initiate a dialogue with the patient to promote the idea of self-care as the basis for maintaining his health at the required level. The use of available communication strategies, including traditional data management tools and innovative ones, will have to be considered. Moreover, it may be necessary to consider engaging the patient’s family members in the process of building health awareness. As a result, opportunities for avoiding health problems in the future will be created (Masters, 2015).

References

k33psimple. (2018). Web.

Masters, K. (2015). Role development in professional nursing practice (4th ed.). New York, NY: Jones & Bartlett Publishers.

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