Running head: HEALTH HISTORY AND PHYSICAL EXAMINATION 1

Health History and Physical Examination

Ashley Wims

Chamberlain College of Nursing

NR: 304 Health Assessment II

Summer B 2016
 2
HEALTH HISTORY AND PHYSICAL EXAMINATION

Health History and Physical Examination

I would like to introduce you to a 33year old African American male. He’s married, his

wife and him currently have 3 children, two boys whose ages are 11 and 2 and one girl whose 6

years old. He’s an employee of a Styrofoam cups and utensils factory, for the last 11 years,

which involves working in extreme heat, chemicals, standing for an extended time period, heavy

lifting, and long hours. He’s in the clinic today for a yearly physical. He was diagnosed with

hypertension 4 years ago and currently take Atenolol 50mg daily. His current weight is 215lbs

he’s 73inches tall his temperature is 98.2, with a respiratory rate of 16, heart rate of 72, blood

pressure 120/76, and pain rate of 0 on a scale from 1-10. Pt believes he’s in good health and

currently has no concern or issues. He has no allergies, received all vaccines as a child, he gets

the flu shot yearly and his last Tdap vaccine was given 2 years ago after the birth of his last

child. His father suffered a heart attack in his mid-40’s he’s currently on blood pressure

medication but otherwise in good health. His mother is also alive and healthy. He has 3 brothers

and 2 sisters with no health conditions. My patient is alert and oriented times 4, he has normal

facial expression, body position and movement. His verbal and nonverbal expression are

congruent, he follows command, his speech is articulate, pattern and content appropriate. His

hearing is good and he has good personal hygiene as well. He doesn’t have any developmental,

cultural, or psychosocial considerations. He has the support of his wife, kids, parents, brothers,

sisters, and a host of cousins and friends for any help if needed.

Objective Data
 3
HEALTH HISTORY AND PHYSICAL EXAMINATION
After I gathered all of my patient’s subjective data I started my assessment. His head was

symmetric without any abnormalities. Pupils where equal round reactive too light and

accommodating, and his cardinal field was good as well. His nose and mouth were pink and

moist without any abnormalities. Then I took the bell of my stethoscope and auscultated the right

side of his neck then the left, I palpated his neck for any swelling of his thyroid or lymph nodes.

After that normal assessment I moved on to his respiratory system. With his shirt off I inspected

the rise and fall of my patient chest then I auscultated his right upper lobe, left upper lobe, right

middle lobe, left middle lobe, right lower lobe and finally his left lower lobe then I went to his

back and repeated this procedure. His skin was normal, I noted no respiratory disturbance, his

lips was moist and pink, his capillary return was less than 3 his breathing was normal in room

air. I than took his apical pulse for 60 seconds, then I auscultated for his aortic valve, pulmonic

valve, erbs valve, tricuspid valve and finally the mitral valve. I than compared the apical pulse to

the radial pulse. I took his femoral pulse his popliteal pulse, tibia pulse and his pedal pulse. I

compared his legs for symmetry and edema and gathered all normal results. Then I asked my

patient to lay down to assess his ABD. I inspected his abdomen, asses for bowel sounds in all

four quadrants and regions and assess abdominal aorta and renal arteries. When I find that

assessment to be normal I moved on to his musculoskeletal system I inspected first then watched

for active movement, then palpated the skin muscles and bony articulation and joints than

proceeded to preform passive range of motion, and finally finishing with testing the muscles for

size strength and tone.

In my finding of this physical examination I found this patient to be very knowledgeable

about this current health condition and lifestyle changes needed to improve his quality of live. He
 4
HEALTH HISTORY AND PHYSICAL EXAMINATION
has successfully changed to a low sodium diet and limited fried greasy food to twice a week. He

has also started working out 3 to 4 days a week from 1 to 2hrs at a time. He is managing his

weight and limiting his alcoholic beverages however, he confessed there is room for

improvement in that area.

This patient didn’t have any physiological, developmental or cultural influences

preventing him from receiving care. He seems like a strong person who can be very determine to

stay healthy. We discuss his diet and the ways his wife has changed the way she prepares food,

he also talked about how often his brothers and him go to the gym and the different exercises

they challenge each other to perform. Although, the changes to his diet and increase in activities

are great I do believe there is room for more teaching about his condition and drinking.

Therefore, the proposed health education for this patient would be managing his hypertension.

Heart disease is the leading cause of death in the United States, 1 out of 3 or about 70

million people are living with hypertension (Weltermann, Kersting, Viehmann). 52 percent have

uncontrolled hypertension leading to an increase in heart disease (Weltermann, Kersting,

Viehmann). Most people aren’t aware of the changes that need to be made in order to manage

their hypertension (Weltermann, Kersting, Viehmann). My patient had no idea of the effects of

alcohol and his blood pressure.

Needs Assessment

For this patient my two health education needs would be eliminating alcohol and

education on hypertension and the severity of mismanagement of this condition. Numerous

studies have analyzed the association between alcohol consumption and blood pressure levels.

That found strong evidence of heavy or regular use of alcohol will increase blood pressure
 5
HEALTH HISTORY AND PHYSICAL EXAMINATION
dramatically especially in African Americans (Akhmedjonov, Suvankulov). Hypertension is a

condition in which the force of the blood against the artery wall is too high. If this patient

continues to drink 4 to 5 times a week it will place him in the 52% of American living with

uncontrolled hypertension in America (Akmedjonov, Suvankulov). Uncontrolled high blood

pressure can lead to stroke by damaging and weakening the brain’s blood vessels, causing them

to narrow, rupture or leak (Akmedjonov, Suvankulov). Uncontrolled hypertension can also lead

to disability, a poor quality of life or even a fatal heart attack (Akmedjonov, Suvankulov).

Fortunately, with treatment and lifestyle changes high blood pressure can be controlled and

reduce risk for life-threatening complications.

Reflection

I used everything I learned to conduct this assessment. When communicating with this

patient the biggest barrier I had to overcome was getting him to take his condition serious and

committing to make the necessary changes. The only way I was able to get through to him was

when we discuss how uncontrolled hypertension would affect his family. I didn’t anticipate the

challenge it would be to convince him to live a healthier lifestyle and limit his alcohol intake.

However, I was very pleased with the outcome, and my patient’s commitment with making the

necessary changes. I do wish I had all the patient current and past history prior to doing the

assessment. The next time I will ask as many question as I can to gather as much information on

my patient as possible so I can be as helpful as possible.

 6
HEALTH HISTORY AND PHYSICAL EXAMINATION

Reference

Akhmedjonov. A., & Suvankulov, F., (2013). Alcohol consumption and its impact on the risk of

High blood pressure. Drug and Alcohol Review, 32(3), 248-253. Doi: 10:1111/j. 1465-

3362.2012.00521

Weltermann, F., Kersting, C., & Viehmann, A., (2016). Hypertension Management in Primary

Care. Deutsches Aerzteblatt Internation. 113(10), 167-174. Doi: 10.3238/arztebol

2016.0167
 7
HEALTH HISTORY AND PHYSICAL EXAMINATION