NU610 health assessment. Unit 1 Case Study 1000w. due 3-13-22. 3 references. APA format cover page.

NU610 health assessment. Unit 1 Case Study

1000w. due 3-13-22. 3 references. APA format cover page.

A 50-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80. He has hypertension, which he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain. Denies seasonal or drug allergies. He has two younger siblings with no known chronic medical conditions. Last eye and dental exam two years ago. He is married in a monogamous relationship without children. Has a high school diploma. Works full-time for local landscaping business. He does not smoke, drink alcohol, use any recreational drugs and does not exercise. He denies fever, chills, weight loss or weight gain. He denies hearing changes, headaches or dizziness. He reports some visual changes when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling or chest pain. He reports increase urination and thirst. Denies abdominal pain, nausea, vomiting or changes in appetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to working outside. Denies anxiety or depression. On examination his blood pressure is 126/82, pulse is 80 beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs. Does not appear in acute distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time and situation. Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal and reactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses, thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruits auscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to auscultation. No use of accessory muscles or purse lip-breathing. Soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. He reports he has not had HIV or PSA screenings.

Please complete the assignment that I have started below. Follow attached template.

Subjective data.

● Chief complaint: Routine physical examination

● History of present illness: Denies any present illness or symptoms. However, he states he

has some visual changes when reading up close. He also reports increased thirst and

urination.

● Past medical history: The patient notes he has hypertension but denies any other

significant medical history.

● Allergy identification: Denies any seasonal or drug allergies.

● Medication reconciliation: The patient states he takes Tylenol as needed for pain and

takes chlorthalidone 25 mg PO daily to manage his hypertension.

● Social history: The patient denies any smoking, recreational drug use, and consumption

of alcohol. The patient states he monogamous and married without children. The patient’s

highest level of education is a high school diploma. The patient works in landscaping.

● Family history: The patient’s father died at the age of 73 due to a heart attack. The

patient’s mother and siblings have no known health problems.

● Health promotion: The patient states that he does not exercise. The patient notes he has

not had a dental or eye exam for the past 2 years. The patient also notes he has not had his

blood pressure checked in the last 5 years.

● Review of systems: The patient denies fever, chills, weight loss, or weight gain. He

denies hearing changes, headaches, or dizziness. He also denies shortness of breath,

dyspnea on exertion, swelling, or chest pain. The patient reports daily bowel movement

and denies abdominal pain, nausea, vomiting, or changes in appetite. The patient also

denies any skin changes such as rashes or bug bites. Anxiety, depression, numbness, and

tingling were also denied by the patient.

Objective data

Patient presents for physical exam. blood pressure is 126/82, pulse is 80beats/min, respiratory

rate is 18. Height is 67 inches and weight is 190lbs. Does not appear in acute distress, responses

are appropriate and appears reliable source. Alert, oriented to person, place, time and situation.

Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal and

reactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray

with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable

masses, thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruits auscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to

auscultation. No use of accessory muscles or purse lip-breathing. Soft, non-tender, nondistended,

normoactive bowel sound. No organomegaly or guarding. Denies numbness or

tingling

Assessment:

Patient is a 50-year-old, well nourished male presenting as new patient to office. Here for routine

physical exam. Patient has hypertension, well controlled with medication. Denies any major

health issues at this time. States that he has some visual changes when reading close-up. Sates

that he has increased thirst and urination. Physical exam ultimately unremarkable.

Plan for patient:

Labs: CBC, CMP, HGA1C, lipid panel, HIV and PSA and visual acuity

Therapeutic: NA

Educational: educate on importance of regular exercise and impact on sedentary lifestyle.

Consultation/Collaboration: NA