Comprehensive Health Assessment Paper

1716 WordsMar 5, 20157 Pages
Running head: A COMPREHENSIVE HEALTH ASSESSMENT OF M. H. 1 A Comprehensive Health Assessment of M. H. Nicole M. Henneberg Empire State College A COMPREHENSIVE HEALTH ASSESSMENT OF M. H. 2 The purpose of this paper is to discuss the results of a comprehensive health assessment on a patient of my choosing. This comprehensive assessment included the patient 's complete health history and a head-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a reliable source. Other sources of data, such as medical records, were not available at the time of the interview. Physical examination data was obtained…show more content…
Her current prescription medications include a 225 mg tablet of Venlafaxine HCL once daily for anxiety related dizziness, and a 20 mg tablet of Atorvastatin for high cholesterol. She drinks alcohol socially, approximately two 12 ounce beers a day. She is a former smoker of one pack of cigarettes a day for nearly forty years. Her quite date was September, 2011. She denies the use of street drugs. A COMPREHENSIVE HEALTH ASSESSMENT OF M. H. 4 Review of Systems M. H. states that she is generally in good overall health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems. No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,
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