Patient Assessment Overview

Study Notes

Patient Assessment Assignment

Patient Demographics (Missing): The document provides a template for collecting patient data (name, address, age, date of birth, etc.), but the data itself is missing
Reason for Encounter (Missing): The document provides a template for recording the reason for the patient's visit to the healthcare provider.
Present State of Health: Patient is a healthy male, of average build, well-nourished, and oriented to time, place, and person.
Health Goals: Client aims to manage work and school-related stress, exercise twice weekly, and eat regularly.
Health Definition: The patient's definition of good health is having a good life.
Chief Complaints: Severe back pain accompanied by fatigue and lightheadedness.
Reason for Seeking Care Today: Patient has fainted twice in the past week.
History of Present Illness: Onset of symptoms two days ago. Location of pain: spine and head. Duration of symptoms: maximum three days. Character: Arching pain and lightheadedness.
Aggravating Factors: Weekdays, night shift, and full-day weekends at school.
Relieving Factors: Decreased activity, sleep, and pain killers.
Pain Severity: Pain is rated as an 8 out of 10.
Allergies: Patient is allergic to NSAIDs.
Expectations for Care: To determine the cause and receive treatment for the current condition.
Past Health History: No known medical, surgical problems, or mental health conditions.
Childhood Illnesses: Chicken pox (twice).
Hospitalizations: History of malaria and allergic reactions (NSAIDS).
Accidents/Injuries: Broke left tibia(shin bone) from a fall at age 15.
Acute/Chronic Illnesses: None
Immunizations: Fully immunized.
Transfusions: None
Alcohol Use: Occasional consumption.
Family History (General): Template for collecting family medical history data is present, but specific information is missing.
Environmental History (General): Template for collecting environmental history data is present, but specific information is missing.
Psychosocial History (General): Template for collecting psychosocial history data is present, but specific information is missing.
Review of Systems: Vital signs (temperature, pulse, respiration rate, SpO2, weight) are recorded. The physical examination of the patient shows that the patient is young adult, well-hydrated, not pale, and has a temperature of 37.6 C, pulse of 77 bpm, respiratory rate of 18 cpm, and saturation of 99%. Also, the patient has an unsteady gait, lightheadedness, headache, blurred vision temporarily.
Skin: Dark, warm, even distribution of hair, well-hydrated, moist, and elastic. No signs of jaundice or cyanosis.
Head: Symmetrical skull, well-rounded face, no protrusions, occipital bones are flattened. No tenderness.
Eyes: Symmetrical, equal pupils with clear margins, brown pigmentation on the left iris, no exudates or hemorrhages.
Ears: Well-formed, no deformities, clean auditory canals.
Nose and Sinuses: Prominent, no discolorations, unperforated septum, no discharges. Mucus membrane is pink; no tenderness.
Mouth: Lips are symmetrical, slightly pink. Mouth is moist, clean, and no visible masses.
Teeth: 32 teeth in number, no plaques, and good condition.
Gums: Gums are pink, not spongy, no bleeding.
Tongue: Situated centrally, pink, average size.
Throat: Pink and vascularized, no visible sores.
Neck: Cervical nodes are not palpable. Trachea is medially situated, symmetrical, with no palpable neck masses. Lymph nodes are small and moveable with no tenderness.
Respiratory Pattern: No accessory muscles involved in respiration. Lungs are well-expanded. Airway is clear. Breath sounds clear.
Cardiovascular: Pulse 77 bpm, blood pressure 129/90 mmHg. No chest pain, dyspnea, or palpitations.
Gastrointestinal: No pain with swallowing. No vomiting. Nausea present. Bowel movements two daily.