Health History and Examination Essay Example for Free

Health History and Examination Essay Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications): Patient is alert, awake and oriented. Denies headaches, head injuries, dizziness, seizures, tremors, migraine, difficulty in speech and swallowing. No history of falls. Patient does mention that he has numbness and tingling of fingers and toes occasionally. Takes Gabapentin 100mg orally three times a day. Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Patient denies neck or head injuries, denies swelling or lumps on neck and head, Denies neck pain or headaches. Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications): Patient wears eyeglasses that are with him. Bilateral cataract surgery done in June 2013. Regular vision checks after surgery done in November 2013 and at present he is not on any medications at home. Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): No complaints of ear pain, infection, surgery tinnitus due to noise, or vertigo noted. Not on any medications. Hard of hearing right ear but does not use a hearing aid. Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): Denies discharge from nose and throat, denies presence of sores or lesions in the mouth. Denies nose bleeds, bleeding gums, or sore  throat. No known allergies noted. Has upper and lower dentures that patient cleans with Polident tablets daily. History of Tonsillectomy at age 7. Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications): Patient’s skin color is ethnic. Has some gray hair but no alopecia. Has well groomed nails. Denies skin problems. Particular about usage of moisturizing lotions after bath. Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to b reast, mammography, breast self-exam, medications): Patient denies any problems with breasts and axilla. Does not perform self-breast examination. Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications): Denies leg pain, cramps or discoloration of arms and legs. Complains of occasional swelling on ankles. Takes Lasix 40 mg orally once a day. Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications): Denies any chest pain or tightness. Denies shortness of breath or weakness. Complains of occasional cough relieved by Robitussin DM 10ml orally every 6 hours as needed. Patient is hypertensive and had an MI in 2005 but denies any history of Congestive Heart Failure. Family history shows that his father died of heart attack at age 75. Patient had an echocardiogram and stress test done last year as outpatient and per patient results were normal. Patient is taking Aspirin 81mg orally daily, Lopressor 25mg orally daily, and Plav ix 75mg orally daily. Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications): Has occasional cough that could be due to change of climate. Denies shortness of breath or pain with breathing. Denies smoking and no history of lung disease is noted. Immunized for Influenza and Pneumonia on 10/14/2013. Patient was in ER in March for cough and fever and x-ray of the chest showed no abnormalities at that time. Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain;  difficulty with activity of daily living, medications) Denies any symptoms of joint problems and does not take any medications at home. Patient is independent and requires no assistance for activities of daily living. His wife and he take walks on a daily basis for 20 minutes. Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications) Denies any gastro-intestinal disease, ulcers, or diabetes. Consumes low sodium diet with no added salt three times a day and a bedtime snack. Includes plenty of vegetables and fruits in his diet. No swallowing problems noted. No complaints of nausea, vomiting or diarrhea noted. Patient has daily bowel movement and reports that it is brown in color. Denies use of stool softener or laxative. An Endoscopy and Colonoscopy was done in January 2014 and no abnormalities noted at that time. Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, supra pubic region or low back) Denies pain or any urinary problems. Patient verbalizes increased frequency of urination due to Lasix. Patient wakes up twice at night to urinate but he is continent of bladder. Per patient no prostate problem noted. Last prostate exam was done in February 2014. Physical Examination (Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments): Patient is awake, alert, and oriented with no memory loss. Patient is calm, cooperative and pleasant. Judgment is intact. Patients speaks clearly and in full sentences. No difficulty noted while speaking. No swallowing problems noted. Patient has a steady gait with full strength. Sensations present in all extremities. Complaints of occasional numbness and tingling of fingers and toes but denies upon examination. 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): Skull and neck are normal on examination. No deformities or hematoma noted. No lymph nodes identified on palpation. Adam’s apple present. Trachea is normal on palpation. Eyes (test visual acuity, visual fields, extra ocular muscle  function, inspect external eye struct ures, inspect anterior eyeball structures, inspect ocular fundus): Patient has eyeglasses with him. Patient is able to open and close his eyelids. Pupil is round and reaction to light is constriction to both eyes. Denies any blurring, watering, or tearing of the eyes. No redness or infection noted. Ears (inspect external structure, otocopic examination, inspect tympanic membrane, test hearing acuity): Hard of hearing right ear with no hearing aid. As per patient the physician had recommended hearing aid for the right ear but patient did not wish to use it. Otoscopic examination revealed normal ear canals and eardrums with minimal amount of earwax. Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat): Nose, mouth and throat are normal on examination. On palpation no pain noted to sinuses. The upper and lower dentures fit well on the patient and do not become loose while talking or chewing. 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): No skin break down or rashes or lesions noted on inspection of the skin. Color is normal to ethnicity. Skin is warm, dry an d intact. Mucus membranes are pink and moist. Hair is gray and no alopecia noted. Texture of hair is soft to touch, no split ends noted. Kept short and clean. No ingrown nails or cracked nails noted. Nails are well groomed and pink in color. Patient verbalizes examining the skin and nails everyday while taking a shower. 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): Bilateral upper extremities are warm, symmetrical with bilateral radial pulses 2+. Bilateral lower extremities are warm, symmetrical without any discoloration. No varicose veins noted. Bilateral pedal pulses 2+. A trace of edema is noted on both ankles and feet. Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S1 and S2, any extra heart sounds, murmur): Carotid arteries are normal with pulse 2+. No jugular vein distension noted. Apical pulse is 82 beats per minute, BP of 150/80 mm of Hg. Heart sounds S1 and S2 are on auscultation. No murmur or extra heart sound noted. EKG shows a  Normal Sinus Rhythm. Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds): Thoracic cage is normal and symmetrical. No abnormality noted on palpation and percussion. Breath sounds are clear and equal on auscultation in all lung fields. Respirations are even, regular and unlabored. Patient has occasional nonproductive cough relieved by cough medicine. Respiratory rate is 18/minute and Oxygen saturation is 99% on room air. Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformi ty, pain, range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and range of motion): Cervical spines are normal in size, no pain or deformities noted with full range of motion. Bilateral shoulders are equal in size, no swelling or mass noted. No pain noted on movement of shoulders. Bilateral elbows, wrists and hands are equal in size, with full range of motion and equal in strength. No deformities noted on inspection. Bilateral hips are equal in strength, no swelling or mass noted. No evidence of redness or injury noted. Sacrum is intact. Bilateral lower extremities with full range of motion and equal strength noted. No swelling or deformity noted. Bilateral ankles and feet noted with trace of edema. Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness): Abdomen is flat and non-distended. Bowels sounds present in all four quadrants. Abdomen soft and non-tender on palpation. Percussion revealed tympany in all four quadrants. Umbilicus is midline and inverted. Surface of abdomen smooth and even, with homogenous color. No lesions or surgical scars noted. Genitourinary System (deferred for purpose of this  class) FHP Assessment Cognitive-Perceptual Pattern: Patient is alert and oriented, no memory loss. Well educated, and has the ability to read, write and understand information. Patient uses eyeglasses for reading and is hard of hearing right ear. Nutritional-Metabolic Pattern: Patient eats a low sodium diet with no added salt three times a day with a bedtime snack. Home cooked food with vegetables and fruits included in the diet are his preferences. The patient or his wife prepares the food. The patient and his wife do the food shopping. Sexuality-Reproductive Pattern: The patient has three children and 5 grandchildren. He is not interested in sexual activities but loves to spend time with his wife. Pattern of Elimination Patient is continent of bladder and bowel. Urinary frequency is increased due to effect of medication (Lasix). Pattern of Activity and Exercise: Patient is independent in activities of daily living. He is not involved in vigorous exercise but walks daily for 20 minutes along with his wife. Pattern of Sleep and Rest: Patient usually sleeps for 6-7 hours at night with an afternoon nap for 30 minutes. Patient wakes up twice at night to urinate but goes right back to sleep with no difficulty. Patient denies use of sleeping pills. Pattern of Self-Perception and Self-Concept: Patient is well dressed and has self-respect and respects others too. He leads a disciplined life with the ability to take care of himself and his wife. He is friendly with his neighbors and is an active participant in church activities Summarize Your Findings (Use format that provides logical progression of assessment.) Situation (reason for seeking care, patient statements): Name: Lawrence Kelly Age/Sex: 72 years/Male Presenting complaints: Increased swelling of ankles and feet, numbness and tingling of fingers and toes, and occasional cough. Background (health and family history, recent observations): History of present complaints: Patient complains of swelling of feet and ankles for 2 weeks with numbness and tingling of fingers and toes. Occasional cough for last one week. Past medical History: Hypertension, MI, Hard of hearing (Right Ear). Medication history: Lasix 40mg orally daily Aspirin 81mg orally daily Plavix 75mg orally daily Lopressor 25mg orally daily Gabapentin 100mg orally three times a day Assessment (assessment of health state or problems, nursing diagnosis): Mr. Lawrence Kelly 72 year old male presented with complaints of swelling of feet and ankles with numbness and tingling of fingers and toes for the past 2 weeks. Occasional cough for the past one week. He is alert, awake and oriented with steady gait. Hard of hearing in the right ear. His vital signs are BP150/80 mm of Hg, Pulse 82, RR 18/minute, and Temp of 98.4. No chest tightness or pain verbalized. Breath sounds are clear and equal in all lung fields. Abdomen soft, non-tender and non-distended. Bowels sounds present in all four quadrants. No difficulty in urination verbalized and color of urine is amber. Trace edema noted on feet and ankles. Pedal pulses is 2+. Nursing Diagnosis: Fluid Volume Excess manifested by edema of feet and ankles. Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education): Blood tests should be done including Comprehensive Metabolic Panel, Vitamin B12 Level, and BNP. X-ray Chest is recommended to find out if patient has CHF Echocardiogram could be repeated as it was done more than 6 months ago Teach the patient to monitor BP, Pulse, Intake and Output, and Daily Weights. Advise the patient to elevate the lower extremities on pillows to reduce  dependent edema Encourage the patient to read food labels on the sodium content Avoid fried foods, canned and frozen foods (Nanda Nursing Interventions, 2012) Provide information about community services such as Heart Center at Barnabas Health, Phone No. 1-888-724-7123 (Barnabas Health, 2013). References: Barnabas Health. (2013). Barnabas Health Heart Centers. Retrieved from http://www.barnabashealth.org/services/cardiac/index.htmlLifestyle and home remedies. Retrieved from http://www.mayoclinic.com/health/heart-failure/DS00061/DSECTION=lifestyle-and-home-remediesNanda Nursing Interventions. (2012). Nursing Interventions for Fluid Volume Excess. Retrieved from http://nanda-nursinginterventions.blogspot.com/2012/04/nursing-interventions-for-fluid-volume.html

Traditional vs. Modern Society Essay -- Anthropology Culture Society E

Traditional vs. Modern Society In today's world, the modern person is educated, independent and aggressive. To be a success, you must put forth your most competitive side and win it all. Nothing less will be permitted. This is the mindset of most business tycoons, stockbrokers and the like. However, on the other side of the globe, third world countries follow a more traditional lifestyle where the outlook on life is a little less malicious. In these countries, the society's idea of success is being part of a large family with prosperous crops and livestock. How is it that our society and theirs have both been successful? And why has the traditional way of life stayed so prevalent in such an industrialized world? First, what exactly does a traditional society entail? A traditional society has many distinguishable traits. A big difference is the rate of illiteracy in these societies. Since everyone in the family is working together to survive, no one has the time or energy to learn how to read and write. Education is considered an indulgence in traditional societies. Farming is the main career - low urbanization and more rural communities fill these areas. Farming is not meant to bring profit, like in a modern society; it means survival for these people. Many people are needed to reap a field when the crops are ready. Therefore, many children must be born. The birth rates in third world cultures are very high as a result. Males are obviously preferred. Because of the...

Popul Vuh

There are many stories that talk about the creation of the earth and have been passed from generation to generation. However, each culture and each region has its own stories about the creation. They are unique in some way but still share the same themes that are universal to many civilizations. Almost all the themes talk about how we and everything on earth were created or how the universe and humanity developed. Two of the most popular creation stories are the Book of Genesis and the Popol Vuh.While the Genesis and Popol Vuh are different in the way God created iving things and their explanation of creation, their similarities are important because they tell us how everything come from and the people's belief in Gods. First of all, the Genesis creation myth is known as one part of the Hebrew Bible that explains how God created human and living things. Therefore, their entire traditional stories seem as the views of a monotheistic world, praising one, all-perfect deity.Genesis focus es mainly on the relationship between God and humans beings in the earth. While the Popol Vuh is one of the Maya creation stories and also showed the perspectives of a polytheistic culture, believing and living under various Gods. In this story, the Gods tried to create something that would praise them and thanks to them. In Genesis myth, God created man and woman to live and love each other. However, one strict rule that Gods did not want them to violate was not to eat an apple from the Tree of Knowledge in the Garden of Eden. Of every tree in the garden thou mayest freely eat: but one of the tree of the knowledge of good and evil, thou halt not eat of it: for in the day that thou eatest thereof thou shalt surely die. † (Genesis 67). Meanwhile, in the Popol Vuh, Gods did not create human at first. Instead, they created animals first and then they created mud people and wood people secondly. Gods finally created humans who made from the corn and have the shape exactly like wha t human nowadays beings. Unfortunately, in both stories, the creation did not satisfy their creators. They did mistake and fail to meet the Gods' expectations.For the Genesis, Adam and Eve were nticed by a serpent and ate the fruit anyway even though they were warned before by the God. Feeling angry from their mistake, God forced them out of the Garden and began to be multiplied and full-filled in the earth. From another part of the Genesis, God was unhappy from what he created because the humans at that time were very greedy and did not follow God's expectations. Therefore, he created a great flood on the earth, destroying everything and killing everyone from this flood. â€Å"l will destroy man whom I have created from the face of the earth,†¦ or it repenteth me that I have made them. (Genesis 70). In contrast, in the Popol Vuh, when animals, mud people and wood people could not reach Gods ‘expectations because they did not praise the creators as they wanted them to do . Therefore, Gods made a flood to kill all the mud and wood people. â€Å"The manikins, woodcarvings were killed when the Heart of Sky devised a flood for them. † (Popol Vuh 82). While God in Genesis gave humans a second chance to live by saving life for Noah's family after destroying everything, Gods in Popol Vuh began to create the corn people after a flood to serve for their desire because they could praise the Gods and did everything that they wanted. as created and how it was ended. Gods in both stories created humans on the earth, gave them food and shelters but also destroyed humans by a great flood as a symbol of their anger when they failed to their expectations. One more similarity between two stories that all Gods were selfish and being scared when people gain too much knowledge. For example, in the Genesis, God did not want Adam and Eve at the forbidden fruit because they will know everything about the nature as the Gods were doing.While in the Popol Vuh, when the Gods saw the corn people were very intelligent and perfect after created, so they felt threatened by the corn people as they would be more powerful than them. miet they'll become as great as gods, unless they procreate, proliferate at the sowing, the dawning, unless they increase. † (Popol Vuh 85). In order to solve this problem, Gods took away some In conclusion, even though the Book of Genesis and the Popol Vuh were written by wo different cultures, they also have some similarities in general such as the creation of the flood and human's knowledge.However, their myths were also different in some way. For the Genesis, God Just wanted people to live happily and healthily on the earth while the Gods in the Popol Vuh stories want people to praise for their merit and keep their day together. Therefore, as we can see that the differences between two stories are very important because they showed us how different cultures and regions affect human's life and thinking about their cr eation.

Essay on Career Interest Deciding on a Career - 1859 Words

Career Interest Deciding on a career has been a challenge. My first career interest was to be a physical therapist. As a child I would look at my mother-nursing textbook was intrigued by the muscular and skeletal systems The most intriguing part was how muscles, tendons, and ligaments all work to attach themselves to our skeletal system to create motion. My second career interesteas in mass communications. After only one semester I realized that I had no real desire to pursue a career in this field. The around the same time I was offered a promotion as the evening manager at my part-time job. I quickly change my major to business administration In hopes of becoming a hotel G. M. and completed my associates degree in business†¦show more content†¦By this time, my old Apple IIc was a relic. My father purchased Packard-Bell that year for Christmas. This computer was way more advanced than the little Apple that I previously owned. I offered to set the computer up. Usually, I wou ld just start plugging in cords and connecting what ever needed to be connected. But this time, I read all the directions before I started. At the time we had everything a printer, fax machine, and scanner. The scanner is till this day is still wanting to be installed. Then, I installed the software and drivers. I was so into this small task that I consider for the moment this being a career option. I shook of the consideration because I had made up my mind to major in physical therapy. A few months passed and the modem stopped working. We received a new one by mail and I was eager to get the device installed. I opened up the computer and was totally intrigued by all the separate parts connecting to make on unit. I look up all the parts, and definition for those parts to try to get a better understanding of how the whole system worked. I was so inclined that I was able to impress my father, who is a self-proclaimed computer expert, with my new acquired knowledge. 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