12 brachioradialis patellar achilles Babinski reflex Negative Musculoskeletal

12 brachioradialis patellar achilles babinski reflex

This preview shows page 12 - 15 out of 16 pages.

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brachioradialispatellarachillesBabinski reflexNegativeMusculoskeletalWalk across room heel to toePerformed without difficultyWalk on tiptoes, then walk on heelsPerformed without difficultyRomberg signPerformed without difficultyShallow knee bendPerformed without difficultiesROM of spineFull resistance. Complete range of motion.D. Analyze from comprehensive health assessment The assessment of a healthy 57 y/o African American male who presents in need of an annual assessment, otherwise he is healthy. He denies pain, nausea and or vomiting. His past medical history includes hyperlipidemia with dietary and exercise monitoring of pre-hypertensive state. He has no known surgical history. His assessment notes that he appears healthy, well-nourished and hydrated and he is within normal BMI. He is very pleasant, alert, oriented x3, and his mood and affect are appropriate. He denies any visual, hearing deficits, or focal neurological deficits. My Patient's speech is clear and appropriate. The assessment concludes there are no frontal or maxillary sinus issues. Vital signs are within normal limits, and no swelling and or deformities were noted upon review. His skin remains intact, warm, dry, and dark brown in color, with no lesions or rashes noted. Patient can complete range of motion without difficulty. He has full strength in his extremities, neck, and spine. His grips, flexion, and extension are strong and equal bilaterally. There were no involuntary movements noted during the assessment. My patient can stand from the seated 13
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and laying position without difficulties. No deviation in gait noted, no limp noted. His bowelsounds were normal active in all quadrants and were non-tender to percussion. His pulse was regular in rhythm and rate, no bruits noted.Recommendations: Recommend: Patient to continue with exercise and diet modification with his cholesterol levels. Incorporate meal planning into his health plan. Recommend: Order a Lipid panel and chemistry Panel. With this being his first appointment, we will need to establish a base-line for care. Recommend that he follows up with primary care after his blood work is complete for monitoring and follow-up as recommend for his well visits for his age group every2-5yrs.E. Comprehensive Health Assessment vs. Physical Health AssessmentA comprehensive health assessment is inclusive of the patient’s chief complaints, and a history of present illness. There is a thorough review of current medications patient istaking, vaccines, a review of systems, patient's medical history, family history, social history and the physical examine. A comprehensive health assessment takes place on the patients initial or first visit with their primary care provider. The questions asked are age appropriate. The assessment provides information needed for continued collaboration regarding the patients’ health. It gives an overall picture of the patients’ health along with health factors in which may affect the patient’s performance. It also allows for the
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