Babinski reflex Normal reflex. The patient’s toes did not fan out and the big toe did not move upward Musculoskeletal Walk across room heel to toe Patient was able to walk across room heel to toe Walk on tiptoes, then walk on heels Patient was able to walk on tiptoes and then on heels. Romberg sign No balance deficits. Shallow knee bend Patient was able to do a shallow knee bend. No pain present. Steady gait throughout. ROM of spine Spine is midline and straight. No abnormalities noted. No pain or tenderness. 5/5 strength. Normal limits of ROM. Analysis of Comprehensive Health Assessment AT is a 28-year-old male that has arrived in the clinic today for his yearly 12
checkup. Patient currently lives with his wife, in a single family home. Patient is currently employed as a software architect. Patient has no medical or surgical history. Patient denies tobacco use, alcohol use or drug use. Patient does not have any family medical history; both parents and sisters are alive with no current medical issues. Patient does not currently take any medications. Patient follows with a primary care provider regularly. Patient reports not childhood medical history. Patient is up-to-date on all vaccines and flu vaccine. Patient has no known drug or food allergies. Patient appears to be a relatively healthy 28 year old. Patient reports having some left hip pain while doing strenuous activities such as playing sports; patient is currently following with an orthopedic physician at this time, as well as working with physical therapy. Lab Tests No laboratory testing identified. Justification As previously stated, patient appears to be a healthy 28 year old, with no past medical history and no family medical history. This RN would recommend that the patient continue to follow with his physician about left hip pain and continue to work with physical therapy. Tests that may be suggested if left hip pain does not improve will be a MRI of the left hip to identify if there are any underlying issues. Comprehensive Health Assessment vs. Physical Health Assessment A comprehensive health assessment is obtained by gathering as much information as possible about the patient, including the patient’s medical history, surgical history, family history, lifestyle and habits, lab results and diagnostic testing results, and also 13
obtaining information about the patient’s chief complaint or reason for visit. During this assessment, the healthcare professional is establishing a relationship with the patient by answering questions and providing teaching. A physical assessment is the assessment of the whole body. This includes vital signs, inspection, percussion, palpation and auscultation of the patient’s body in order to collect information to create a diagnosis. In order to create a whole picture of the patient, and have an understanding of the patient as whole, both a comprehensive health assessment and physical assessment must be completed. Resources 14
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- Spring '16
- Shelley Ashby