Health Assessment Check-Off Project Essay Assignment paper
Health Assessment Check-Off Project Essay Assignment paper
The patient is a 20-year-old male who presented to the facility with complaints of intermittent headaches. The headache was largely periorbital and diffused to other regions, so the head spread through the jaws, the nose, and the cheekbones. The patient reported no known history of diabetes and hypertension. There was no known history of surgery or diagnostic test related to the illness, such as eye surgery. The patient reports no blurring of vision, numbness, rhinorrheas, tearing, and diplopia. Health Assessment Check-Off Project Essay
Past Medical History (Hx):
Health Assessment Check-Off Project Essay Assignment paper
No past medical history of chronic illnesses such as hypertension, diabetes, cancer, cardiovascular diseases, or psychiatric diseases.
Past Surgical Hx:
No history of hospital admissions, minor or major surgery.
Family Hx:
First son in a family of three children. No familial history of chronic illnesses.
Social Hx:
Possesses a bachelor’s degree in a local university. Single,
no social history of abuse of illicit drugs but occasionally drinks alcohol with friends.
Allergies:
Has seasonal allergies, denies food or drug allergy.
Medications:
Allegra for seasonal allergies, but she has not been using the recent past medications. The medicine is used to treat seasonal allergies (Zelig et al. 2016).
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Review of symptoms by the system:
Physical Exam:
On physical examination, the patient’s vital signs were within the normal hemodynamic range as follows, temperature 98.7F, blood pressure 126/78 mm/Hg, pulse 80 b/min, Spo2 99%, and respiratory rate of 22 b/min.
General Appearance
Clean and well-groomed adult with no signs of acute distress.
Skin
Moist, warm, and clean, with no evidence of lesions and bruises.
HEENT
Head- normocephalic with no evidence of trauma or lesions. The teeth- clean and in good condition. Health Assessment Check-Off Project Essay
Cardiovascular
Regular heart rhythm, and no murmurs, no gallop rhythm, S1 and S2 heard.
Respiratory
Symmetrical chest wall. Regular respiratory rate, with no increased effort on breathing. The lungs were clear bilaterally on auscultation.
Gastrointestinal
Symmetrical abdominal wall, no distension. Active bowel sounds in all four abdominal quadrants. Non-tender and soft on palpation.
Genitourinary
The urinary bladder was non-tender and not distended. The hair distribution on the pubic region was even, and the skin color was consistent with the rest of the body with no observable pigmentation.
Musculoskeletal
The patient demonstrated a full range of motion of all four extremities.
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