NR 304 RUA Health History and Physical Assessment

NR 304 RUA Health History and Physical Assessment

Student Name

Chamberlain University

NR-304: Health Assessment II

Prof. Name:

Date

Health History: Subjective Data

P.B. is a 56-year-old African American male, originally from Jamaica and currently residing in New York. English is his primary language. He stands 6 feet 1 inch tall and weighs approximately 280 pounds. He is married and presented for his routine annual health checkup, reporting no current illnesses or medical concerns. P.B. views health as the presence of wellness and the absence of disease, and he considers himself to be in good health.

He smokes approximately five cigarettes per day and consumes alcohol about three times a week but denies any use of recreational drugs. His vaccination history is complete, including routine childhood immunizations, a COVID-19 vaccination in June 2021, and a flu shot administered in October 2021. He reports no known drug or food allergies and is not currently taking any medications. P.B. does not have a significant personal medical or surgical history. However, he mentioned that his father died from cancer in 2019 and his mother from dementia in 2018.

He reports no skin conditions such as rashes, bruising, or skin cancer. He denies headaches, visual changes, or hearing difficulties and has never worn corrective lenses. P.B. has not experienced respiratory issues such as wheezing, coughing, or dyspnea. His cardiovascular history is unremarkable, with no history of irregular heart rhythms, murmurs, or venous complications. He also denies any gastrointestinal or genitourinary issues, such as appetite changes, constipation, bleeding, or urinary problems.

Neurologically, he denies seizures, weakness, or stroke symptoms but mentions seasonal joint stiffness in his knees during colder months. He has never sustained fractures. His last prostate examination occurred in May 2021. According to Erikson’s psychosocial theory, P.B. is currently in the “Generativity vs. Stagnation” stage, focusing on contributing to future generations. He emphasized the importance of family in his upbringing and noted a cultural practice of using a mix of rum and honey as a home remedy for illness. Although he does not practice organized religion, he holds spiritual beliefs in a higher power.

Physical Examination: Objective Data

P.B.’s physical exam reveals the following vital signs:

NR 304 RUA Health History and Physical Assessment

The general examination indicates a normocephalic head without lesions or infestations. Eye inspection reveals pink and moist conjunctiva, white sclera, and pupils that are 3 mm, equal, round, and reactive to light. There is no ear discharge, and he successfully passed the whisper test. The nasal structure is symmetrical without inflammation or drainage, and bilateral patency is noted. The throat appears moist, and both the thyroid and lymph nodes are nonpalpable and non-tender.

Cardiovascular examination shows a regular heart rhythm with no murmurs or edema. Respiratory findings are normal, with clear breath sounds bilaterally and no accessory muscle use. His mental status is alert and oriented to person, place, time, and situation. The abdominal assessment reveals a soft, rounded, and symmetrical abdomen with active bowel sounds in all quadrants and no signs of tenderness or distention.

Musculoskeletal evaluation finds full range of motion in all extremities with a muscle strength of 4/5. His gait is balanced and steady. The peripheral vascular and neurological systems are within normal limits, and all cranial nerves are intact.

Needs Assessment

Educating patients about modifiable lifestyle factors is vital to prevent disease and promote overall well-being. Based on P.B.’s health history and assessment, he appears generally healthy, with the exception of elevated blood pressure levels that place him in the prehypertensive range.

Recommendations for improving his health include smoking cessation and reducing alcohol consumption. According to Mostofsky et al. (2016), heavy alcohol intake is associated with increased risk of hypertension. Additionally, P.B.’s smoking habit, although not currently impacting his lungs, may contribute to reduced pulmonary function and long-term cardiovascular complications. Research by Tantisuwat and Thaveeratitham (2014) highlights that smoking negatively affects lung expansion and respiratory muscle strength, which could later impact vital functions such as oxygenation and circulation.

Family and social support are essential to sustaining behavioral change. By involving his close family members in his care plan, P.B. can benefit from both emotional encouragement and practical support. These relationships can play a crucial role in motivating and educating him to adopt and maintain healthier habits.

Reflection

The interaction with P.B. was smooth and positive. A comfortable and respectful approach was maintained throughout the assessment, applying communication and clinical skills gained from Health Assessment courses I and II. There were no major challenges during the interview or examination process. The only limitation was the lack of detailed information regarding P.B.’s extended family medical history, particularly on his grandparents’ health conditions.

In future assessments, it would be beneficial to allow the patient more time to recall and provide comprehensive family history. Encouraging patients to gather such information ahead of appointments can enhance the quality of the assessment and support better preventative planning.

References

Mostofsky, E., Mukamal, K. J., Giovannucci, E. L., Stampfer, M. J., & Rimm, E. B. (2016). Key Findings on Alcohol Consumption and a Variety of Health Outcomes From the Nurses’ Health Study. American Journal of Public Health, 106(9), 1586–1591. https://doi.org/10.2105/AJPH.2016.303336

NR 304 RUA Health History and Physical Assessment

Tantisuwat, A., & Thaveeratitham, P. (2014). Effects of smoking on chest expansion, lung function, and respiratory muscle strength of youths. Journal of Physical Therapy Science, 26(2), 167–170. https://doi.org/10.1589/jpts.26.167