Health History Examination
FUNDAMENTAL IN ADULT CARE
Individual Client Health History Examination of an Older Adult
Client/Patient Initials LNP Sex: F. Age
Occupation: free-lance researcher- journalist
Health History/Review of Systems
Neurological System -- the patient seldom suffers headaches or dizziness. She has no difficulty speaking or swallowing. She only takes vitamin and mineral supplements on a daily basis. She sits long hours before a computer because of her work, however. And thus experiences numbness in the legs and feet.
Head and Neck -- except for stiff neck due to computer work, she does not suffer from any significant causes in this area.
the patient is highly myopic and occasionally experiences visual migraine. She wears contact lenses but no medications.
Ears -- Nothing abnormal or disturbing about her hearing
Nose, Mouth and Throat -- no disturbing nose, mouth or throat discharges except for 3 defective teeth that need root canal therapy.
Skin, hair and nails -- no color changes, dryness, bruising, hair loss, nail problems. Patient's skin is clean and soft.
Breasts and axilla -- no tenderness, no lumps or discharges, swelling or injury.
Peripheral, vascular and lymphatic system -- leg pains and cramps but no swelling. Leg pains are relieved by stretching from ergonomic work.
Cardiovascular system -- no chest pain or tightness, no coughs or swelling of the hands or feet. She does not tire easily but walks fast for hours with very little fatigue. She does not take any heart medications.
Thorax and Lungs -- no coughs or painful breathing and no history of lung disease although she smoked for 10 years and then stopped. No flu or TB shots.
Musculoskeletal system -- joint stiffness and muscle pains most of the day because of daily and intense computer work.
Gastrointestinal System -- no appetite problem or difficulty swallowing. Food is well tolerated. She seldom suffers from loose bowel movement or constipation or ulcers. She has been eating brown rice and whole wheat products for 3-4 years now.
Genitourinary system -- no abnormal discharges or pain except for pain in sitting down for long hours before the computer for online work.
Physical Examination
Neurological System -- no abnormalities in...
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