Complete Health History and Physical Assessment: Case Study

Read a complete health history and physical assessment case study of a patient with high blood pressure, high levels of triglycerides and cholesterol, excessive smoking habit and morbid obesity leading to poor quality life and possibility of depression. Learn about the patient's biographic data, history of present illness/health, review of systems, physical assessment, and health promotion needs.

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Washington Adventist University
Edyth T. James Department of Nursing
NURS244: Health Assessment and Health Promotion
Complete Health History and Physical Assessment: Case Study
Name of Examiners: ____________________________________ Date: ______________
Biographic Data
Patient’s Name: __________Jack green ______________________Age:___55__ Date of
Birth:____24th April, 1963_______
Address: _____225 Broadway, Fl. 19, New York, NY 10038, phone:
(+1)656.203.120________________________________________
_____________________________________________
Gender: _____ M _____ F Marital Status: _widowed______ Occupation:
_________________used car salesman__
Race/Ethnic origin: _____White American_________________ Employer:
____________J.B.B Car sales company_________
Source and reliability
The patient was himself present to undertake the health assessment interview and therefore the
information was highly reliable
_________________________________________________________
Reason for seeking care
High levels of triglycerides and cholesterol, high blood pressure, excessive smoking habit and
morbid obesity leading to poor quality life and possibility of depression
_________________________________________________________

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History of Present Illness/Health
Review of Systems
General Overall Health: height: 6.1”, weight 346 pounds and BMI: 45.6
Skin: warm along with pink undertones found, no presence of bruising and was well perused,
history of eczema or several other skin infections were not found
Hair: hair loss was absent and there was no change in texture of the hair as well
Nails: nails were strong and no change in shape was found
Head: mo presence or complain of headaches were found, no migraines, no prior injuries in the
head were found.
Eyes: difficulty in vision was not found, it was clear
Ears: no earaches of infections were found
Nose and Sinuses: changes in the sense of smells were not found, no known allergies or
discharge were found.
Mouth and Throat: inflammation of the gums, cavities and bad breath, chronic sore throat along
with sudden excess of saliva, facing difficulty when swelling, feeling of lump throat and
uncomfortable feeling
Neck: cervical lymph nodes were clear and proper in condition, no abnormal deviation of trachea
was found, condition of the thyroid gland was also up to the mark

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Breast/Axillae: palpation and percussion of the chest showed no negative condition, auscultation
of the lungs also revealed no negative results; axillary lymph nodes were inspected and found in
proper condition
Respiratory: chest x-ray showed the passage to be clear and there were currently no cough or
sputum observed, symptoms of asthma, bronchitis, pneumonia or tuberculosis were not found.
Mild ronchi that was present during emergency admission was also not found in the follow up
and coughs were absent.
Cardiovascular: high blood pressure was found about 180/100 that was indeed a reason of
concern, however complains of heart trouble was not reported, heart murmurs were not present,
chest pain discomfort that was present during emergency admission was also not found, however
some of the palpitations or skipped heartbeats were seen which might be due to cardiomegaly
symptoms. Heart burns are also experienced by him sometimes probably due to his GERD
conditions.
Peripheral Vascular: sweating was present and the palms were also found to be clammy, swelling
in the legs mainly due to edema, no swelling or redness is found in the other parts of the body
Gastrointestinal: sometimes pain occurs in the abdomen, the pain might be due to the irritating
effects of the stomach acids in the inner esophagus wall, this might be because the inner lining of
the esophagus does not have the same natural protection from acid that exists in the stomach
lining
Urinary: frequency or urination was found to be higher than that of the normal, nocturia is
present with the needs of urinating 3 to 4 times per night, often suffers from incontinence or due
to leakage of the urines, sudden urge to urinate, painful urination is also complained some of the
times.

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Genital: non-cancerous enlargement of the prostrate resulting in issues in urination, absence of
scrotal pain and swelling, testicular pain and swelling are absence, no history of sexually
transmitted disorders as well as the other sexual discomfort
Sexual Health: no sexual life as such, however complained if reduced sex drive and issue in
keeping an erection along with less sexual satisfaction
Musculoskeletal: muscle of joint pain along with stiffness, arthritis and gout as well as backache
and others are not present, swelling is however found in the legs that might be due to edema of
cardiomegaly.
Neurological: fainting, blackouts and seizures are completely found to be absent along with no
signs of dizziness, vertigo, numbness and tingling sensations. However, he suffers from low
mood and sudden changes in mood, insight or judgment; however, he was polite and stable
during the interview.
Hematologic: no complaints of anemia as well as easy bruising or bleeding and even past
transfusion and transfusions reactions were present and found in the patients
Endocrine: excessive sweating was found that but did not show any signs of excessive thirst and
hunger as well as polyuria and even change in glove or shoe size. No thyroid trouble and no heat
or cold intolerance was also found.
Physical Assessment
Patient Name: _____Jack Green_________________________________________________
General Survey: ______________________________________________________
_________________________________________________________________
_________________________________________________________________
Ht.______6’1”____ Wt.__346________ Waist circumference__40 inches ________
BMI_____45.6_____
Snellen Vision Chart Right eye__no significant findings________ Left eye_____ no
significant findings _____ Correction____ no significant findings _____

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BP______180/100____ sitting/standing T__________ P__________ R__________
Pain Assessment: ___so pain was noted during the time of visit, chest pain and heart burn are
found sometimes due to
GERD._____________________________________________________
____________________________________________________________________
____________________________________________________________________
SKIN: sweating and clammy skin
HEAD AND FACE: no significant findings
EYES: (no significant findings)
EARS: no significant findings
NOSE: no significant findings
MOUTH: inflammation of the gums, cavities and bad breath, THROAT:
NECK: chronic sore throat along with sudden excess of saliva, facing difficulty when swelling,
feeling of lump throat and uncomfortable feeling
CHEST AND LUNGS:
Anterior: clear (no significant findings)
Posterior: clear (no significant findings)

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UPPER EXTREMITIES: (no significant findings)
BREASTS: (no significant findings)
NECK VESSELS: (no significant findings)
HEART: cardiomegaly (enlarged hart)
ABDOMEN: high abdominal circumference due to calorie deposition
INGUINAL AREA: no significant findings
LOWER EXTREMITIES: edema in both legs
NEUROLOGICAL: suffers from low mood (rest no significant findings)
MUSCULOSKELETAL: swelling is however found in the legs due to edema
GENITALIA: non-cancerous enlarged prostrate

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HEALTH PROMOTION: State 3 areas where health promotion is needed for this patient.
a 1._the patient is not being able to understand the importance of healthy diet in his life and
therefore, he is still having fast foods. The fast foods and the take-away foods are usually higher
in calorie and hence results in calorie deposition in the body leading to increased weight content
(Eldredge et al., 2016). Moreover, food low in salt content is also important for managing his
blood pressure. Hence, healthy foods need to be consumed by him.
_________________________________________________________________________
Patient Education: the patient should be included in a one-to-one education session where the
nurse would use brochures, flyers and educational materials to help the patient understand the
risks factors associated with taking fast foods (Hubley & Copeman, 2018). Developing his health
literacy and making him understand his improper health habits would make him motivated to
change his lifestyles. As he is keen on developing the condition of his health, these one to one
discussion sessions with the patient may help in changing his dietary attributes (Edelman et al.,
2017).
2.__the patient has smoking habits and are seen not being able to reduce his smoking frequency.
Smoking might also result in increased chances of high blood pressure. The chemicals in the
tobacco smoke causes damage in the lining of the artery walls. This makes the walls of the artery
to become narrow and these factors result in increasing the blood pressure because the blood has
to flow through the narrow blood (Thomas et al., 2017). This might result in life threatening
situations and therefore it becomes very important for the nurse to educate the patient about it
and change in
outcomes______________________________________________________________________
__
Patient Education:

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Motivational interviewing can be taken as the patient education strategy. The patient needs to be
well aware about the harmful outcomes of smoking and needs to develop the motivation to
withdraw smoking habits himself. Motivation interviewing technique would help in invoking the
feeling and determination among the patient making him understand the outcomes of his sever
smoking habits (Fertman, 2016). When the nurse would be able to involve the patient
successfully in the session, there would be high chance that the patient will develop motivation
to overcome smoking habits and stick to his objectives. Smoking cessation planning should be
developed for him and he should be also advised to participate in smoking cessation classes.
3._the patient seems to be withdrawn from his life as the loss of his wife had severe impact on
the emotional stability of the patient. The patient feels low on mood that might be due to the
grief of losing his wife who used to take good care of him and helped him to stay healthy. He
seems to be depressed but he is unaware of this depression. With the passing of time, he might
become more depressed and this might affect his quality of in life (Becker et al., 2017). Hence,
the patient should be educated about the interventions and strategies that he can undertake to
prevent him from being affected by the mental-
disorder_______________________________________________________________________
__
Patient Education:
The patients should be first made to be aware of the symptoms of depression. This would help
the patient to relate his own conditions with the symptoms of depression and accordingly be
aware of his present mental health conditions. Accordingly, the patient would be allowed to
understand and be educated about the treatment procedures of depression like the anti-depressant
medications, therapy with the mental health specialists (Barrett et al., 2018). The patient would
be also educated about the strategy of the combination of mental health therapy and education
and accordingly take part in the interventions to help him develop his mental state and live happy
lives with family members. He can participate in cognitive behavioral therapy

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References:
Barrett, Stephen, Stephen Begg, and Michael Kingsley. "Surgeons and preventative health: protocol for a
mixed methods study of current practice, beliefs and attitudes influencing health promotion
activities amongst public hospital surgeons." BMC health services research 18.1 (2018): 780.
Becker, C. M., Felts, W. M., Chaney, B., & Johnson, M. (2017). Going on Offense to Enable Health
Promotion Gains. New Measures for New Directions Jessica Grossmeier, PhD, MPH, 31(5), 451.
Edelman, C. L., Mandle, C. L., & Kudzma, E. C. (2017). Health Promotion Throughout the Life Span-E-
Book. Elsevier Health Sciences.
Eldredge, L. K. B., Markham, C. M., Ruiter, R. A., Kok, G., Fernandez, M. E., & Parcel, G. S.
(2016). Planning health promotion programs: an intervention mapping approach. John Wiley &
Sons.
Fertman, C. I. (2016). Health promotion programs: from theory to practice. John Wiley & Sons.
Hubley, J., & Copeman, J. (2018). Practical health promotion. John Wiley & Sons.
Thomas, J., Ross, L., Hansen, A., & Smallwood, S. W. (2017). Campus Health Promotion Planning Using
the National College Health Assessment (NCHA): Is There Value Added When Assessing
Readiness to Change?.