Running head: HEALTH HISTORY AND PHYSICAL ASSESSMENT RUA 1

Health History and Physical Assessment RUA

Jenna Anderson

Chamberlain College of Nursing

NR 304: Health Assessment

2 April 2017

Professor Moersch
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Demographic Data

JR is a 57-year-old Caucasian male. He currently lives in St. Charles, Missouri in a

suburban area with his family. He lives with his wife, son, and daughter. He also has another

daughter who lives close by. JR works as an electrical engineer for MasterCard. His job does not

require any dangers any body systems, although, he does live a sedentary lifestyle.

Reason for Seeking Care

JR came into the office for an annual check-up following his diagnosis with kidney

cancer and removal of his left kidney. He noted fatigue and some blood in his urine related to his

diagnosis. JR decided he needed to have check-ups regularly as a preventative measure for any

other illnesses that may become present during his lifetime. His urologist recommended he see

his primary care physician yearly to prevent any further complications with his present illness

and prevent any other illnesses.

Present Illness

JR present illnesses are anxiety and depression. Since the death of his father and his

diagnosis with cancer he notes that his depression and anxiety have gotten worse. He states

“Now that the surgery to remove my kidney is over and I am cancer free I may be a little less

anxious, but I am still worried.” The main needs of the patient are to address his feelings about

his recent cancer diagnosis and educate him on further prevention and signs and symptoms of

any complications.

Perception of Health

JR thinks that being healthy means being free of diseases as well as maintaining a healthy

weight for the individual. He states that people remain healthy be exercising regularly and eating

a well-balanced diet. JR knows he is not the healthiest because he does not exercise regularly. He
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states he used to love exercising, but he is having knee pain related to aging. JR knows he should

change is habit and start eating healthier and exercising, but does not seem motivated at the time.

He states that his wife usually does the cooking so maybe they could start a healthy lifestyle

together.

Past Medical History

JR was diagnosed with kidney cancer in July 2016. He had surgery to remove his left

kidney in August. No cancer had spread to other parts of his body and is currently cancer free. JR

states that he will get a CT scan every six months for the next two years and yearly after that as

preventative measures. JR also has anxiety and depression. He states that he “has had this for too

many years to count.” He currently takes medication every night for his depression and anxiety

as well as a sleeping pill, but he could not recall the names of the medications.

Family Medical History

JR has six brothers and sisters, two of which also have anxiety and depression. His

mother is still alive and recently moved into a nursing home. She suffers from osteoporosis and

broke her hip seven years ago. She also has Type II Diabetes and is insulin dependent. JR should

really watch his weight and adhere to a healthy lifestyle in order to prevent diabetes. His father

died over a year ago. He had a hiatal hernia, and outpouching of the part of the stomach

through the opening of the diaphragm into the thoracic cavity, that caused him to be

unable to eat (VanMeter, Karin, & Hubert, 2014, p. 450). He put off going to the doctor which

caused him to become weak. His father eventually had surgery to remove the hernia, but had

many complications leading to his death. JR should monitor his health and visit his doctor

regularly to prevent life-threatening complications.

Review of Systems
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JR states his overall health is good, but good be improved. He has had no excessive

weight loss or weight gain or any weakness. JR has had some moles removed by his

dermatologist, but states they were benign, noncancerous. H states, “I do have some dry skin on

my cheeks, under my eyes and I put Cortisone 10 on it almost every night.” JR does note some

hair thinning due to aging, but denies any nail changes. He states, “I do not get outside much

except to mow the lawn, but when I am I use sunscreen and a hat to prevent sunburns.” JR denies

any headaches or dizziness. He wears glasses regularly, but states he has not been to the eye

doctor in a couple of years. JR denies any ear pain or ringing of the ears. He does not have

exposure to loud noises with his occupation. JR denies allergies, but states, “I did just get over a

cold.” He usually does not take medication when he gets sick besides maybe cough drops. JR

does not have any mouth or tooth pain. He denies mouth sores of bleeding gums. JR states that

he does go to the dentist for his yearly check-ups. JR denies any neck pain or any enlargement.

He also states he has no pain, tenderness, or swelling of the breast and armpits. JR denies any

history of lung diseases. He states,” Sometimes I get short of breath doing activities like mowing

the lawn.” He states he just had a CT scan of his chest and abdomen in December at his follow-

up appointment after his kidney surgery. JR denies any chest pain, tightness, or palpitations. He

also states he does not have any trouble breathing while lying down or at night. JR states he has

not noticed any numbness, swelling, or discoloration of his hands or feet. His states he does sit a

lot at work, but never crosses his legs. JR states that he loves to eat and denies any changes in

appetite and no heartburn or indigestion. He denies any history of abdominal diseases. He states,

“My bowel movements are very regular, every morning, and I am known to be the gassy one in

the family.” JR does have a history of kidney cancer. He did have some bloody urine before the

diagnosis, but after the removal of the tumor that subsided. He denies any discomfort or
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hesitancy while urinating. JR has frequent follow-up visits with his urologist, especially after his

cancer diagnosis. He denies any pain, lesions, or sores of his perineal area. He does not have any

penile discharge or testicular pain. He states he does not do testicular self-exams. Education on

the technique and frequency were given to JR. JR does state some pain in his right knee. He

states, “It is worse with exercise, and better if I avoid any harsh movements.” He denies any

other muscle pain or weakness. JR has stated he has anxiety and depression, but denies any other

neurological problems such as numbness, tingling, tremors, mood changes, or hallucinations

(Jarvis, 2016, p. 54-56).

Developmental Considerations

According to Erickson’s theory, JR is in the generativity versus stagnation developmental

stage. JR has a successful career and is happy with his occupation. He has been married to his

wife for 28 years and they have three children together. JR feels his happy with his life and how

he has raised his children. He states, “I would not change anything about my life. I am happy

with it and would not be where I am today without going through what I have.” I believe that JR

is meeting the correct milestones for his age and is meeting the generativity stage in Erickson’s

developmental stages theory.

Cultural Considerations

JR has lived in the United States all his life. English is his primary language; therefore, he

knows how to speak, read, and write in English correctly. He has never been out of the United

States so he never had to face a language barrier. He identifies himself as Catholic, but states he

does not attend church regularly. Therefore, JR does not have any cultural issues a health care

provider needs to be considered with.

Psychosocial Considerations
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JR has a diagnosis of anxiety so stress is a very big part of his life. He states work can be

stressful, especially when he has projects or presentations due. JR states that he relives his stress

by watching television, especially sports, and spending time with his family. He has also learned

some guided imagery techniques from his doctor that he has been practicing and states, “I enjoy

it and feel it really helps me unwind and be less anxious.”

Collaborative Resources

JR stated that he did go to a support group after his father passed away because he was

having trouble grieving over the loss. I suggested he go to these support groups at least once a

month to just help him talk about anything stressful that has happened in that month. He has

many hospitals close to him if necessary as well. He is a member of the Rec Plex, but does not

use it very often because of his knee pain and recently kidney removal. I suggested getting back

in a routine of working out even if it is just going for a walk. He has many grocery stores nearby.

He said his wife usually does the cooking, but I suggested maybe doing the shopping together or

doing some cooking classes together just for some fun and maybe a new hobby they can do

together. I suggested his local Dierbergs for cooking classes. They have many different ones that

him and his wife could attend and they could do it once a month.

Physical Exam

During the physical exam, JR noted that he does not have any known allergies. His skin

is warm, dry, and even skin tone. It is free of any lesions, rashes, and bruising. JR’s hair is free of

any lesions and infestations. His hair is thinning and some gray strand noted. This is a normal

finding for his age. JR’s nails are clean, smooth, and have a curve of less than 160 degrees. His

capillary refill was less than two seconds. His head is normocephalic without any lesions or

bruising. His facial expressions are adequate for the situation as well. JR’s eyelids and eyebrows
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are symmetrical without any tenderness or edema. His eyelashes and eyebrow hair are evenly

distributed. There are no lesions or discharge around JR’s eyes. His sclera is white and his

conjunctiva is pink and moist. The top of JR’s ears are aligned with the outer part of the eye. He

has no swelling, tenderness, or drainage of his ears. There is also no skin breakdown behind the

ears. JR states that he cleans the insides of his ears with a Q-tip every morning. His nose is

symmetric and midline to his face. There is no drainage, lesions, or foreign bodies on inspection.

There is no deviated septum noted. JR’s nares are patent bilaterally. JR’s tongue and gums are

pink and moist without any lesions. His posterior pharyngeal is also pink and free of swelling

and lesions. JR’s tonsils are a 1+. His uvula is midline and reactive. JR’s neck and trachea are

symmetric and midline. There are no masses or tenderness along the trachea. There is no thyroid

enlargement or tenderness. JR has no carotid pulsations visible and no jugular vein distention at

45 degrees. There was no tenderness or swelling on palpation of the preauricular, post auricular,

occipital, tonsillar, submental, submandibular, superficial cervical, posterior cervical, deep

cervical, and supraclavicular lymph nodes. JR’s chest ration is 2:1 with no deformities or barrel

chest. His respirations are even and unlabored. No signs of distress or use for accessory muscles

or nasal flaring. There are no masses or tenderness on the anterior and posterior chest. JR is erect

with no signs of scoliosis, kyphosis, or lordosis noted. Chest expansion and tactile fremitus are

symmetrical. All of JR’s lung lobes are clear. All heart sounds are heard, S1 and S2 are present.

S1 is louder at the apex of the heart and S2 is louder at the base of the heart. No murmurs are

noted over the aortic, pulmonic, tricuspid, or mitral valves. JR’s radial pulse is +2 with a regular

rate and rhythm. His abdomen is symmetric with no pulsations noted. JR’s abdomen is convex

with even skin tone and no masses or bulges noted. One eleven inch scar going diagonally along

the left side and four other scars each two inches along the abdomen from his kidney removal
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surgery. Bowel sounds are heard hyperactively in all quadrants. No bruits heard over the aorta,

renal, iliac, and femoral arteries. No abdominal pain, edema, or masses on light palpation of JR’s

abdomen. JR has a smooth and steady gait. He has full range of motion of his neck and back. JR

also has full range of motion and adequate strength bilaterally of all upper and lower extremities.

JR is alert and orientated to person, place, time, and situation. JR’s mood is appropriated for the

situation. His speech is clear and smooth and he is dressed appropriately for the weather. All of

JR’s cranial nerves are intact and appropriated for age. JR’s sensory perception is appropriate as

well. All JR’s reflexes are a 2+. No thrill of bruit of the carotid arteries. All upper extremity

pulses are a 2+. JR’s posterior tibial pulses were a 2+ and dorsalis pedis pulses were a 1+

bilaterally. Popliteal pulse was difficult to palpate and a Doppler should be used.

Needs Assessment

JR needs some education on healthy eating. He stated that he eats out a lot so education

about healthy choices at restaurants is something he could focus on. Education on healthy choice

options like choosing grilled chicken over fried chicken were taught. JR also needed education

on reducing his anxiety. He can do this by relaxation techniques. JR was educated on guided

imagery and meditation to help him reduce anxiety in his life.

Reflection

The interaction between me and the interviewee was just life what was learned in Health

Assessment. I thought the interview went well. It was easy to do the health history since we had

done that part of the interview for Health Assessment I. During the interview, I kept wanting to

use medical terminology instead of terms used that the interviewee could understand. I overcame

this barrier by slowing down and thinking about how to say things so the interviewee would

understand. I also told him to ask any questions when he did not understand something. There
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were no unanticipated challenges in the interview, I was pretty well prepared on what I was

supposed to do. More information that could have been obtained would have been information

related to JR’s kidney cancer. Instead of just knowing it was kidney cancer finding out what kind

of cancer it was and more information relating to his surgery. I think the interview could have

been approached better if I am more organized next time. I kept forgetting things and having to

go back to them especially at the beginning because I was nervous. As the interview went on, I

started to get myself more organized and things seemed to run more smoothly.
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References

American Psychological Association. (2010). Publication manual of the American Psychological

Association (6th ed.). Washington, DC: Author.

Best ways to manage stress. Goal setting and relaxation techniques reduce stress and ease the
physical and emotional burden it can take. (2015). Harvard Health Letter, 40(4), 3.

Carson-DeWitt, R. (2015). Fast Food Salads: Making Smart and Healthy Choices. Health
Library: Evidence-Bases Information.

Jarvis, C. (2016). Physical examination and health assessment (7th ed.). St. Louis, MO: Elsevier.

VanMeter, Karin C. and Robert J. Hubert. (2014). Gould's Pathophysiology for the Health
Professions. (5th ed.). St. Louis, Missouri: Elsevier.