Patient Assessment Overview

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.