Babinski reflex normal reflex the patients toes did

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
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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
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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
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