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Throat and MouthClient reports healthy teeth and gums and denies difficulty chewing, swallowing, or hoarseness. Client reports he gets his teeth cleaned annually. Respiratory
COMPREHENSIVE CLIENT ASSESSMENT10Client denies respiratory issues such as cough, sputum, hemoptysis, and dyspnea while resting or during exercise. Client denies ever having tuberculosis and denies abnormal chest x-rays. Normal respiration rate and rhythm noted. Cardiovascular/Peripheral VascularClient denies tachycardia or abnormal rhythm. . Client denies chest pain while at rest or while exercising. Client denies peripheral vascular issues such as swelling in his legs or feet and pain with walking. GastrointestinalClient denies any gastrointestinal issues or complaints no issues. Client denies heartburn,nausea, vomiting, diarrhea, constipation, and abdominal pain. GenitourinaryClient reports normal urinary pattern and denies increased urinary frequency, urgency, dribbling, hematuria, dysuria, incontinence, or waking at night to urinate. Client denies pain on either side of his lower back. MusculoskeletalClient has full range of motion and denies any history of muscular or skeletal injuries. SkinClient denies skin issues such as rashes, bruises, lesions, and pruritis. HematologicClient denies bleeding or bruising easily and denies any history of anemia. EndocrineClient denies increased thirst, increased urinary frequency, intolerance to heat or cold, changes to his hair, and any other endocrine symptoms. Client denies thyroid issues.
COMPREHENSIVE CLIENT ASSESSMENT11Allergic/ImmunologicClient denies any allergies or immune deficiencies.PsychiatricClient denies issues with falling or staying sleep denies having nightmares. He denies anychanges in his appetite. On scale from 0 to 10. Ten being worse client states his Mood as a 4 and his anxiety and depression 0 of ten. Client denies history or active thoughts of suicide. Denies thought or history of hurting self. Client denies history of any auditory of visual hallucinations. NeurologicalClient denies a history of traumatic brain injury and denies dizziness, syncopal episodes, seizure activity, headaches, weakness, tingling, numbness, tremors, changes in gait, or loss of coordination. Client denies difficulty concentrating or changes in his memory. Physical Assessment and Neurological ExaminationA head-to-toe physical assessment of the client was performed before interview with client by rounding medical doctor. The client’s physical assessment was unremarkable. The client’s height is 5’8”, his weight is 140 pounds. Vitals included 88 heart rate, Blood pressure 120/72, respirations 16, O2 99% on room air. Clients appearance is that of health 16-year-old male no abnormal physical finding reported or assessed Laboratory and Diagnostic TestingA urine screen was completed prior to interview and was negative for all substances, including opiates, buprenorphine, oxycodone, methadone, propoxyphene, barbiturates amphetamines, methamphetamines, benzodiazepines, cocaine, THC, and alcohol byproducts.