Posted: December 30th, 2021

RUA Health History and Physical Assessment

RUA Health History and Physical Assessment
Your Name (without credentials)
Chamberlain University College of Nursing
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RUA Health History and Physical Assessment
The purpose of this paper is to provide a health history assessment of an individual. I have completed the assessment interview with a family member. I will use the initials V.T. to indicate the individual’s name. This health history assessment will be divided into subjective and objective data. The subjective data will include the individual’s demographic data, their personal view on health, their family health history, their personal health history, a review of body systems, their cultural views, their social views, and their access to necessary resources. The objective data will include a thorough head-to-toe physical examination.
Health History Assessment
Demographic Data
V.T. is a 36-year-old Caucasian male. He lives in a ranch-style home in a small subdivision in the middle of rural farmland with his wife and no other family members. He currently works for a utility company. His primary language is English.
Reason for Care
V.T. is currently seeking care for a simple wellness check-up. He is looking to have a head-to-toe assessment conducted to ensure there are no new concerns he needs to be aware of. V.T. stated, “I am not experiencing any issues that I am concerned about, I am just due for a wellness visit”.
Present Illness
V.T. does not have any present illnesses. He stated, “I am not sick or experiencing any unusual signs or symptoms”. V.T. is not experiencing any hospital-acquired illness or complications.
Perception of Health
V.T. defined what he considered to be healthy and unhealthy. He stated, “Being healthy means eating a well-balanced diet, taking vitamins daily and exercising”. He then described ways of being unhealthy. He stated, “smoking is unhealthy, eating fast food is unhealthy, and drugs are unhealthy”. When asked how he felt about his health in comparison to the standards he just provided, V.T. stated, “I am pretty unhealthy”.
V.T. does not feel as though he is very healthy. When asked what he would change about his health, V.T. stated, “Everything! I feel like I am not a very healthy person. I tend to eat way too much junk food and in really large portions. Although I stopped smoking, I still currently chew tobacco which is not much better. The only standard I gave you that I consider to be unhealthy that I do not do is use drugs.” V.T. does not have any current health goals. V.T. stated, “I mean I would like to lose some weight but I just do not have the motivation to try to lose weight again”.
Past Medical History
V.T. has a history of asthma. V.T. stated, “I had asthma as a kid but I grew out of it”. He also has a history of bronchitis. He stated, “I get bronchitis almost every year during the winter”. He typically receives an inhaler but only to use while during his bronchitis episode. V.T. also suffers from heartburn. He stated, “I have to take Nexium to keep my heartburn away. If I forget to take my pill, my heartburn is really bad”. V.T. did not report any additional medical history or other disorders and diseases.
V.T. is not currently on any prescription medications. He stated, “The only thing I take is a Nexium pill every morning for heartburn”. The only known allergies V.T. has is to shellfish. V.T. stated, “I do not think I have any allergies to medications. I just ca not eat seafood or my throat will swell up”. V.T. stated, “My mom had me vaccinated as a kid and I received whatever vaccinations were necessary when I enlisted in the National Guard. I do not get flu shots or any booster shots”. V.T. had no surgical history. His wisdom teeth were removed, but they were not impacted and did not require him to be sedated.
Family Medical History
V.T.’s mother has COPD and Type 2 diabetes, high blood pressure, and high cholesterol. M.L’s father does not have any known medical conditions. V.T. has two sisters. He stated, “As far as I know, neither one of my sisters suffer from any known medical issues”. V.T.’s grandparents on his father’s side are not biologically related. M.L’s father was adopted and he has not given any information on his biological parents. V.T.’s grandparents on his mother’s side are biologically related and have several medical conditions. V.T.’s grandmother has Type 2 diabetes, high blood pressure, and high cholesterol. His grandfather also has Type 2 diabetes high blood pressure and high cholesterol. He also had triple bypass surgery about 8 years ago. Around the time V.T.’s grandfather had his bypass surgery; he was diagnosed with prostate cancer. His prostate was removed and he has not been diagnosed with any other cancers.
Review of Systems
The review of V.T.’s systems was not a physical assessment. This part of the interview is V.T.’s responses to questions asked about each system. He has provided past and current information on these systems.
Review of Head
V.T. is not currently experiencing frequent or severe headaches. He only suffers from an occasional headache that is easily resolved with an over the counter medications. V.T. has suffered from past head injuries. V.T. stated, “I played football in high school and had a few concussions from that. I also did MMA for a little while and during my first fight, I got a concussion”. V.T. has not recently experienced any head injuries and does not experience dizzy spells.
Review of Eyes
V.T. has moderate acuity difficulty and astigmatism that requires him to wear contacts daily. V.T. stated, “Sometimes I experience blurry vision but that is only if my contacts are starting to wear out and I need to replace them”. V.T. does not experience blind spots, double vision, redness, swelling, excess watering, or discharge. Occasionally V.T. experiences eye pain. He stated, “My eyes hurt if I am wearing a pair of contacts and there is a rip in one of them and I can not replace it”. V.T. does not have a history of glaucoma or cataracts.
Review of Ears
V.T. does not have frequent or severe ear infections or earaches. V.T. stated, “I do not have a lot of problems with my ears. I have just noticed that I do not like to listen to music as loud as I use to”. V.T. does have a history of tinnitus. He stated, “I typically have daily ringing in my ears but it usually does not bother me. Every so often, the ringing will be really bad and I will have to close my eyes tight to make it go away”. V.T. believes it could be from listening to loud music and hearing gunfire while serving in the army. V.T. does not have a history of vertigo.
Review of Nose
V.T. stated, “I get sick pretty often during the winter but it is never severe”. He does experience nasal congestions often due to a presumed deviated septum. V.T. stated, “I have had my nose broken several times either from sports or getting into a fight. My nose has not been completely right ever since”. V.T. does not have excessive nasal congestions, just during winter illnesses. He does not have a history of nosebleeds. V.T. stated, “I have had a couple of nosebleeds that were not from being hit, but I think it was because the air was really dry and it irritated my nose”. V.T. does not have a history of allergies. He has also not experienced a change in his sense of smell.
Review of Mouth
V.T. has a history of cavities. He stated, “I do not like going to the dentist so I do not go unless my teeth hurt”. V.T. has had his wisdom teeth removed as well as one molar. He stated, “I had my molar removed after I cracked it on a popcorn kernel”. V.T. does not have gingivitis, however, he does use chewing tobacco. V.T. did have an abscess on his tongue several years ago. V.T. stated, “I bit my tongue and I couldn’t stop messing with it so I think it got infected. I accidentally bit down on the sore and it popped. After it popped and all the stuff came out of it, it started to heal”. V.T. has not had any other lesions on his tongue since. V.T. does not experience mouth pain and has had no change in his sense of taste.
Review of Throat
V.T. does not have difficulty with swallowing. He also does not experience frequent sore throat or hoarseness. He stated, “The only time I have a sore throat is when I am sick, especially if it’s a sinus infection”. V.T. has not had his tonsils removed.
Review of Heart
V.T. does not have a history of heart conditions. He does not experience frequent chest pains, tightness of the chest, or difficulty breathing while lying down or sleeping that is associated with a heart condition. He stated, “I get short of breath while being active but that is just because I am out of shape. And the only time I have difficulty breathing while I am sleeping is from nasal congestion when I am sick”. V.T. does not have a history of heart murmurs or any other abnormal heart sounds. He does not have a history of hypertension, coronary heart disease, or anemia.
Review of Lungs
V.T. does have a history of asthma. He stated, “I had asthma as a kid but I grew out of it”. V.T. does have a history of bronchitis and still has episodes of it during the winter. He does not have a history of emphysema, pneumonia, or TB. V.T. does not typically experience chest pain with breathing. He stated, “I only feel short of breath if I am doing an intense workout”.
Review of Skin
V.T. does not have a history of eczema, psoriasis, or hives. He has not noticed any abnormal changes to his skin tone or changes to any moles. V.T. does experience excessive dryness during the winter season. He stated, “In the winter my skin dries out pretty bad. I notice it mostly on my face and head. It gets pretty itchy and nothing seems to make it better”. V.T. does not typically experience excessive itching when his skin is not dried out from the winter season. He has not experienced abnormal bruising, rashes, or other marks on his skin.
Review of Chest
V.T. does not experience chest pain. He stated, “I only feel short of breath or any kind of chest pain if I am doing an intense workout. And I have not worked out in quite a while”. V.T. has not noticed any lumps around his chest area and does not experience nipple discharge. He has not experienced any rashes over his chest.
Review of Peripheral Vascular
V.T. does not experience any coldness, numbness, or tingling in his legs or arms. He has not noticed any unusual swelling in his legs or feet. V.T. stated, “I have not noticed any changes in color to my hands or feet. They are the same color as the rest of my body”. V.T. has not experienced varicose veins, intermittent pain in his calves, or ulcers on his arms, legs, or feet.
Review of Abdomen
V.T. has not experienced any recent change to his appetite. He stated, “The only time I can think of that my appetite will change is when I am sick. I usually do not have much of an appetite if I do not feel good”. V.T. does have an intolerance to shellfish. He stated, “I use to be able to eat shrimp when I was younger but one day, I was eating it and my throat started to itch and swell up. I have not been able to eat it ever since”. V.T. does have frequent heartburn. He takes over the counter medication to treat his heartburn. V.T. does not frequently experience abdominal pain, nausea, or vomiting. He stated, “The only time I feel abdominal pain is when I eat too much food or if I am sick. And I only get nausea or vomit if I am sick”. V.T. does not have a history of abdominal disease. He does have regular bowel movements. V.T. stated, “I typically poop once a day in the morning and they look normal to me”. V.T. does not have rectal bleeding. He has not recently experienced any changes in his urination. V.T. did experience pain while urinating when he had a kidney stone. He stated, “I felt pain around my back when I was trying to pass that kidney stone”. V.T. does not have a history of any urinary disorders.
Review of Musculoskeletal
V.T. does not have a history of arthritis or gout. He does not have any joint pain, stiffness, swelling, or deformities. V.T. stated, “I have hurt my shoulder before when I was lifting weights but I did not lose any range of motion from it”. V.T. does not typically hear any noises when moving his joints. He does not typically experience muscle pain, cramps, or weakness. He also does not have an abnormal gait. V.T. does not have any issues with coordination activities. V.T. stated, “The only muscle problems I have are lower back pain. I hurt my back when I was younger helping my dad with some construction work”. V.T. has not had any recent injuries to his joints, muscles, or back.
Review of Neurological
V.T. does not have a history of seizures, strokes, fainting, or blackouts. He also does not have any weakness, tics, tremors, or paralysis problems. V.T. stated, “I do not have any numbness or tingling issues”. V.T. also does not suffer from any memory loss disorders, depression, or other mental health disorders.
Developmental Considerations
Erik Erikson, a well-known psychoanalytic theorist, theorized that all individuals progress through life in stages. V.T. is currently in his early adulthood. Erikson believed, “the central crisis of early adulthood is intimacy versus isolation” (Boyd & Bee, 2015, p. 350). This means that during this stage of life, V.T. should be establishing a life-long intimate relationship with another person. If V.T. has not established this relationship, he will be faced with isolation.
V.T. is married and has been with his wife for almost 9 years and married for almost 4 years. He stated, “I feel like I have met all of my adulthood milestones. I am married, I have a career, I own my own home, and can support myself and my wife”.
Cultural Considerations
V.T.’s parents were both raised Catholic but they did not raise him or his sisters under Catholic practices. He stated, “I do not practice any specific religions. I also do not have any specific values or beliefs that I practice”.
Psychosocial Considerations
V.T. is close to some of his immediate family. He stated, “I am very close to my dad. I would consider him to be one of my best friends”. He visits his parents at least twice a month. As of recently, V.T. is not close to either of his two sisters. He tries to keep in contact with some of his extended family and does so primarily through social media.
V.T. has several close friends. He is currently neighbors with his long-time childhood friend who he spends time with weekly. V.T. stated, “I have a handful of good friends but one I would consider my best friend. We have known each other forever”. V.T. stays in contact with is other friends at least a few times a month either by texting or social media.
V.T. has one specific social activity he enjoys doing. He is an active bow shooter and enjoys going to bow shoots. V.T. often goes to these bow shoots with his best friend. He stated, “It is a fun activity that we like to do together”.
V.T. is not currently feeling stressed. He stated, “I do not have anything to be stressed about right now”. When V.T. is feeling stressed, he shoots his bow or hangs out with his dad or his best friend. V.T. often engages in the activities he enjoys and finds relaxing. He stated, “On the weeks I have downtime to be able to do the activities I like”.
Collaborative Resources
V.T. stated, “My wife, parents, and friends are my main support system. They help me get through any tough times I have”. V.T. does not attend church or any support groups. He has access to any resources he needs and they can easily be found within his community. Although he lives in a small rural area, he is not more than 10 minutes from a local grocery store. V.T. does not have a primary physician. He stated, “Any time I need to see a doctor, I go to the local urgent care and get the medical help I need”. V.T. does not attend a gym but he has access to a local gym in his community and a gym near his place of work. V.T. has access to many local grocery stores. V.T. stated, “I have a reliable vehicle of my own that I can use to drive to any of the resources I need”.
Physical Examination Assessment
Head
Upon inspection, V.T. does not have any lesions or infestations. With palpation, V.T. does not have any abnormal bumps or tenderness. V.T. can clench his jaw without any notable pain or tenderness. V.T. can indicate the presence of a gentle touch of a cotton ball to his face with his eyes closed. This indicates cranial nerve V is intact. V.T. can smile, frown, scrunch his face, and puff up his cheeks. This indicates cranial nerve VII is intact. V.T. was able to press his face against my hand and shrug his shoulders when instructed. This indicates cranial nerve XI is intact. V.T. did not show any pain or discomfort when rotating his head.
Eyes
Upon inspection, V.T. does not have any eye discharge or redness. His conjunctiva is pink and moist and his sclera is white and clear. V.T.’s pupil size is 4mm, which is within the normal range. Utilizing a penlight, V.T.’s eye pupils were equal, round, reactive to light consensually, and presented with accommodation. V.T. was able to follow the six cardinal fields of gaze indicating cranial nerves III, IV, and VI are intact.
Ears
Upon inspection, V.T. does not have any lesions or piercings. V.T. does not have any pain or tenderness on palpation. No discharge is present. V.T. was able to repeat back all works whispered during the Whispered voice test. This indicates cranial nerve VIII is intact.
Nose
Upon inspection, V.T. does not have any lesions. His nose is slightly asymmetric. V.T. does have a slight deformity, a deviated septum to the left. There is currently no inflammation or drainage present. V.T. as unilateral patency on the right as his deviated septum cause a slight obstruction on the left side. V.T. was able to identify the fragrance of coffee indicating cranial nerve I is intact.
Mouth & Throat
Upon inspection, V.T.’s lips, tongue, and gums are pink and moist. V.T. was able to swallow a sip of water. When asked to stick out his tongue and say “Ah”, V.T.’s uvula and soft palate both raised. This indicates cranial nerves IX and X are intact. V.T. was also able to stick out his tongue and move it from side to side and press against a tongue depressor indicating cranial nerve XII is intact.
Neck
Upon inspection, V.T.’s trachea is midline. Palpation indicated no masses. The lymph nodes were not palpable which a normal finding is. M.L’s thyroid gland was not enlarged or tender.
Respiratory System
Upon inspection, V.T. is breathing easy and even. There is no use of accessory muscles. V.T.’s lungs were auscultated using the diaphragm of the stethoscope anteriorly in 5 positions. This was done so in a Z-pattern. V.T.’s lungs were auscultated using the diaphragm of the stethoscope posteriorly in 6 positions. This was also done in a Z-pattern. All lung fields were clear.
Cardiovascular System
Upon palpation, V.T.’s carotid pulses are a regular rate and rhythm, 2+ bilaterally. With V.T.’s laying at a 45-degree incline and head turned to the left, there is no indication of JVD. V.T. does not present with signs of edema. V.T.’s heart was auscultated using both the diaphragm and bell of the stethoscope. This was done in five specific locations. No murmurs or abnormal sounds were heard.
Gastrointestinal System
Upon inspection, V.T.’s abdomen is symmetric with a round contour. V.T.’s bowel sounds were auscultated for a full minute starting at the right lower quadrant to the right upper quadrant, left upper quadrant, and left lower quadrant. No abnormal bowel sounds were present. V.T.’s abdomen was lightly palpated in the same order. No tenderness or distention was present.
Musculoskeletal System
Upon inspection, V.T. does not have any redness or abnormalities of his major and minor extremity joint sites. The joints appear symmetric with no abnormal contour. V.T. was able to conduct a full range of motion in each major and minor joint site and was able to indicate muscle strength by pressing back against resistance. V.T. does not present with an abnormal gait.
Peripheral Vascular System
V.T.’s radial pulses are a regular rate and rhythm, 2+ bilaterally. V.T.’s dorsalis pedis and posterior tibialis pulses are also a regular rate and rhythm, 2+ bilaterally.
Needs Assessment
After completing V.T.’s head-to-toe assessment and physical examination, I would advise additional health education on weight loss and tobacco cessation. A negative factor that may impede V.T.’s ability to incorporate the health teachings into his daily living is he does not have the self-motivation to develop a plan and stick to it. Two positive factors would promote V.T.’s ability to incorporate health teachings into his daily living. One is V.T. has a strong support group, his wife, and his parents. Another positive factor is V.T. has the necessary resources within his community and can access them daily.
V.T. is currently overweight. He discussed in his health assessment that he feels unhealthy and would like to lose weight but does not have the motivation to try again. By providing V.T. with additional education on the best approaches to losing weight, it will help him be more successful.
Weight loss is accomplished by eating a quality diet, drinking adequate water, and performing the appropriate workout regimen. To be successful, an individual needs to develop a plan. The planning should mainly consist of meal preparation. By preparing meals for several days, it helps reduce poor eating habits (Tufts University, 2018). If V.T. can develop a meal plan and follow through with meal preparation, he would be more successful in eating a balanced diet and avoid eating junk food that has added to his weight gain. The barrier V.T. faces primarily is self-motivation. However, his support system can continue to encourage his efforts to lose weight by following a meal prepping plan.
V.T. is currently using chewing tobacco. Although V.T. stopped smoking cigarettes years ago, the use of tobacco smoke is also damaging to his body. V.T. acknowledges that chewing tobacco is also unhealthy but does not have the motivation to quit. By providing V.T. with additional education on the negative effects chewing tobacco has on the body, it will help him be more successful in quitting.
Utilizing chewing tobacco as an alternative to smoking is not beneficial. Although chewing tobacco does not introduce toxic smoke to the lungs, it still harms the body. “The International Agency of Research on Cancer has concluded that there is sufficient evidence of carcinogenicity for smokeless tobacco” (Wyss et al., 2016). If V.T. continues to use chewing tobacco, he is at higher risk for cancer. Providing him with education on the risks may help him to quit chewing. The primary barrier V.T. is self-motivation. However, his family is a strong supporter to encourage his cessation of chewing tobacco.
Reflection
To ensure a successful interview, I planned to interview at a time that was most convenient to the interviewee. I decided to interview in a quiet room with no other individuals present. The afternoon was the best time of day to conduct the interview, so I had everything prepared before the afternoon. I utilized therapeutic communication techniques, such as active listening and empathy, throughout the interview (Jarvis, 2020). Active listening encourages the interviewee to speak because they feel acknowledged. Empathy allows the interviewer to connect with the interviewee on a more personal level.
The interview process felt more comparable to what was learned in class because we not only assessed the individual’s health, we performed a physical examination. This interview process helped bring everything learned in health assessment together.
For the most part, the interview went well. I did not have any notable barriers to overcome during the interview. The individual I interviewed on is a family member so he was not uncomfortable with sharing his health history with me or allowing me to perform a physical examination on him. I did my best to keep the interview professional but without making the individual feel uncomfortable. I avoided using professional jargon, medical terms, that the individual would not know. Using professional jargon is considered one of the interview traps that should be avoided (Jarvis, 2020). Since I did not have any barriers to overcome, I would not change any part of the interview for the future.
There were no unanticipated challenges during the interview. I had a list of questions prepared to ask the interviewee before beginning the interview. I wanted to make sure I covered all the required areas. The interview went smoothly and there were no issues to notate.
I did not find there to be any information that I wish I would have had available to me that I did not. Again, I had all the questions I needed to be prepared before the interview. My interviewee was cooperative and answered all the questions I asked.
In the future, I would like to adjust the questions that I ask. The questions I asked were fairly standard. I think if I adjusted the questions to be more guided to that individual, I may get more information. I also need to continue to work on building a rapport with my interviewee since I will not always be conducting interviews on individuals I know personally.

References
Boyd, D., & Bee, H. (2015). Lifespan development (7th ed.) [VitalSource bookshelf version]. Retrieved from https://online.vitalsource.com/#/books/9781323031223/cfi/6/2!/4/2@0:16.6
Jarvis, C. (2020). Physical examination and health assessment (8th ed.) [VitalSource bookshelf version].
Tufts University. (2018). Weight loss: No quick fixes. Tufts University Health & Nutrition Letter, 36(1), 3. https://www.nutritionletter.tufts.edu/healthy-eating/weight-mgmt/weight-loss-no-quick-fixes
Wyss, A. B., Hashibe, M., Lee, Y. A., Chuang, S. C., Muscat, J., Chen, C., Schwartz, S. M., Smith, E., Zhang, Z.F., Morgenstern, H., Wei, Q., Li, G., Kelsey, K.T., McClean, M., Winn, D. M., Schantz, S., Yu, G. P., Gillison, M. L., Zevallos, J. P., Boffetta, P., & Olshan, A. F. (2016). Smokeless tobacco use and the risk of head and neck cancer: Pooled analysis of US studies in the INHANCE consortium. American Journal of Epidemiology, 184(10), 703-716. https://doi.org/10.1093/aje/kww075

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