Physical Health Assessment of Adult

1661 Words Dec 1st, 2013 7 Pages
Health History and Examination

Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems

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Student Name:
Date:

Client/Patient Initials: AAB
Sex: Male
Age: 76
Occupation of Client/Patient: Retired
Health History/Review of Systems
(Complete and systematic review of systems)
Neurological System (headaches, head injuries, dizziness,
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Record findings.)
Neurological System (exam of all 12 cranial nerves, motor and sensory assessments):
All cranial nerves tested within normal limits. Pt passed visual fields exam and no problems with gag reflex. Pt moved muscles evenly and bilaterally and was able to shrug shoulders and move head from side to side.

Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland):
No lumps or abnormal masses palpated. Face looks symmetrical, thyroid gland not enlarged.

Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus):
Pupils equal and round, reactive to light. Wears glasses, had injury to eye in 2008 where traumatic Cataract removed and lens was implanted.

Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity):
Pt denies hearing impairment; acuity tests WNL, earaches, discharge or infection; wax noted in canal, ears are equal in size.

Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat):
No known allergies, no sinus, tenderness, no epistaxis, no bleeding gums, patient has partial dentures, one dental carrier noted, tongue is slightly coated, no swelling, lumps or tenderness noted in throat,

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