Essay about Health History and Examination

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Pages: 7

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: C.B. Sex: F Age:
Occupation of Client/Patient: Retired
Health History/Review of Systems
(Complete and systematic review of systems)
Neurological System (headaches, head injuries, dizziness, convulsions, tremors,
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Some nasal discharge noted
Mouth: Negative for canker sores or lesion
Throat: No lesions are redness noted
Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach self-examination techniques):
Skin: Clean and intact. No breakdown noted
Hair: Clean and dry. Mild dandruff noted
Nails: Trimmed and neat
Breasts and Axilla (deferred for purpose of class assignment)
Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps):

Arms symmetrical. Pulses palpable. Patient walks with a limp