NR 304 Assignment RUA Health History and Physical Assessment Guidelines

RUA Health History and Physical Assessment Guidelines

Student Name

Chamberlain University

NR 304

Instructor Name 

Submission Date

RUA Health History and Physical Assessment Guidelines

Health History and Physical Examination

Subjective Data

The patient is a 46-year-old African American male who lives with his wife and two teenage children in a suburban house. He is a fulltime information technology project manager. He comes for a well-visit checkup at the health clinic as part of his company health program.

Reason for Care

The participant denies any relevant acute complaints and only the desire to maintain the control over their blood pressure and check their weight since they have been experiencing gradual weight increase during the last two years.

Present Illness (PQRST)

He complains of a headache due to tension twice a week.

• P: Initiated by the time spent in front of the screen and stress.
• Q: Band-like pressure.
• R: Does not radiate and localized to forehead.
• S: Rates pain 4/10.
• T: 1-2 hours; is relieved with rest and ibuprofen.

No neurological co-morbidities reported.

Perception of Health

His health seems to be fair, and he thinks that he needs to work out more and experience less stress. He denies eating healthy, admitting that he eats processed and fast foods often.

Past Medical History

• Hypertension was diagnosed at 42 years old.
• Childhood asthma (resolved)
• Appendectomy at age 15
• No hospitalization within the last decade.

Medications

• Lisinopril 20 mg a day orally
• Ibuprofen as needed for headaches
• Multivitamin tablet taken once orally daily in the morning

Allergies

NKDA; not allergic to any food, environmental, or chemical agents such as pollen, dairy, latex, or plastics.

Immunizations

Current regarding influenza, COVID-19 boosters, Tdap (less than 9 years old), and completed childhood vaccines.

Family Medical History

• Father: Deceased at 61due to myocardial infarction; history of hypertension.
• Mother: Type diabetes mellitus type 2 diagnosis; deceased at 68 due to natural causes.
• Maternal Grandmother: Diagnosis of breast cancer at age 39; deceased due to cancer complications at age 62.
• Siblings: 43-year-old younger brother; diagnosed with hyperlipidemia and is currently on statin therapy.

Objective

Review of Systems

• Skin: denies rashes, lesions, bruising or pigmentation changes. None of eczema or psoriasis history. No new moles, itch and slow healing of wounds. Reports normal skin turgor.
• Head: Denies any headaches or reports that there are occasional tension-type headaches (twice per week). Denies head trauma, vertigo or syncope.
• Eyes: Wears prescription glasses to presbyopia. Denies blurred vision, double vision, floaters, eye pain, photophobia or excessive tearing. Last vision exam 8 months ago.
• Ears: Denies hearing loss, tinnitus, ear pain, ear discharge, recurrent ear infections. No problems in listening in conversations.
• Nose: Denies nasal congestion, rhinorrhea, nosebleeds, sinus pressure or alteration in sense of smell. Denies any seasonal allergies.
• Mouth/ Throat: denies sore throat, dysphagia, hoarseness, bleeding gums, or oral lesions. Dental visits twice yearly. No TMJ pain reported.
• Neck: Denies stiffness, swelling, or pain or range of motion. None has thyroid disease history.
• Respiratory: Denies cough, dyspnea exertion, wheezing, sputum, orthopnea, or sleep apnea history. Asthma in childhood became cured without further recurrence as an adult.
• Cardiovascular: Denies chest pains, palpitations, edema, orthopnea, or claudication. Admitted hypertension, which is controlled with medication, but denies home BP monitoring. Denies arrhythmias like murmurs or known.
• Breasts (Male): Denies the presence of lumps, tenderness, nipple discharge or change of the skin.
• Gastrointestinal: Denies frequent heartburn following big or late meals. Denies nausea, vomiting, diarrhea, constipation, hematemesis, melena, hematochezia and unintentional weight loss. Appetite stable.
• Genitourinary: Denies dysuria, frequency, urgency, nocturia, hematuria or flank pains. No history of kidney stones or urinary tract infections. Denies dysfunction of normal sexual functioning.
• Musculoskeletal: Denies any muscle pain or stiffness in the lower extremities. Denies joint swelling, redness, deformity or loss of functionality. No history of fracture or chronic joint disease.
• Neurological: Denies seizures, numbness, tingling, weakness, tremors, any coordination change, or loss of memory. No balance or walking problems.
• Endocrine: No history of polydipsia, polyuria, cold/heat intolerance, or thyroid abnormalities. Denies any weight loss or gain.
• Hematologic/ Lymphatic: Denies bruising easily, persistent bleeding, nosebleeds, and swollen lymph node. No anemia history or clotting disorders.
• Allergic/ Immunologic: Denies food allergies, environmental allergies and frequent infections. NKDA.
• Psychiatric: Denies anxiety, depression, insomnia, panic attacks, mood fluctuations, and occasional stress at work. No psychiatric history of diagnoses or treatment. Has balanced interpersonal relationships.

Developmental Considerations (Erikson)

The participant is a 46-year-old, which is the stage of Generativity vs. Stagnation. He shows that he has a sense of generativity by being dedicated to family and professional progress. But he complains that he has not been leading a healthy lifestyle, which indicates that he partially fails to adapt self-care with outer requirements.

Cultural Considerations

The respondent is African-American and cherishes a cultural heritage of the family get-together meals that are based on high fat and sodium food. He considers health to be a joint venture between the medical care and the individual responsibility (Lawn et al., 2020). He is trying to be open to other healing practices like herbal teas but he is not using the traditional healers.

Psychosocial Considerations

He denies drug abuse, alcohol abuse, and suicide attempts. He denies having a strong family support and an active church existence. The elements that lead to occupational stress are the long working hours and the numerous projects that are going on (Bolliger et al., 2022). Listening to music and walking are some coping activities that should be adopted where there is time.

Collaborative Resources

He has individual health insurance, a primary care doctor, a helpful wife, and has a workplace fitness program and nutrition advice that provides discounted gym memberships.

Physical Examination: Objective Data

HEENT

Head normocephalic non-traumatized. Pupils identical, circular and responsive to light. The intact extrapyramidal movement. Pearly gray the ear drums. Nares are pink, no deviation of the septum. Oral cavity moist, no lesions.

Neck

Supple, full range of motion. Thyroid nodule free and unpalpable. Cervical lymph nodes not swollen or tender.

Respiratory

Chest expansion symmetric. Breath sounds clear bi-laterally. No wheezing, crackles and rhonchi.

Cardiovascular

No murmurs, regular rate and rhythm; S1 and S2 intact. None of the jugular venous distension. No peripheral edema.

Neurological

Alert and oriented x4. Cranial nerves II-XII intact. Strength 5/5 on both the upper and lower extremities. Sensation intact. Gait steady.

Gastrointestinal

Abdomen non-distended and soft. In all quadrants bowel sounds active. No masses or organomegaly.

Musculoskeletal

Major joints normal range of motion. Slight paraspinal patient lumbar back pain on long standing. No deformities.

Peripheral Vascular

Bilateral Radial, dorsalis pedis, and posterior tibial 2+ Pulse. No varicosities. Capillary refill <2 seconds.

Needs Assessment

Health Education Need 1: Hypertension and Dietary Sodium Reduction

By relying on both subjective and objective results, the participant needs to receive specific education on how to manage hypertension by eating less and doing more of cardiovascular activities. There is evidence that culturally-specific dietary counseling is strongly effective in regulating blood pressure among African American adults (Keseko et al., 2025). A second study observes that organized lifestyle modification that focuses on the DASH diet lowers systolic blood pressure by 4-11 mmHg (Elmakki, 2024).

Influencing factors

• Physiological: Preexisting hypertension and cardiac history of the family is risky.
• Developmental: Mid-life stage promotes long-term investment health.
• Cultural: Higher sodium-based dietary habits will be a barrier to adherence.
• Psychosocial: Work stress eliminates time to embrace lifestyle changes.
• Strengths: Family support and access to wellness programs are strong, which mean that the chances of the change in behavior are high.

Health Education Need 2: Stress Management and Prevention of Headaches

He has tension headaches and claims work-related stress, meaning that some education should be provided to him on stress-reduction and ergonomics. Wells et al. (2021) notes that mindfulness-based stress reduction reduces the number of headaches and perceived stress in adults with tension-type headaches. Musculoskeletal stress and headaches associated with screens are minimized through ergonomic modification and periodic rest (Guduru et al., 2022).

Influencing Factors

• Physiological: The office work promotes migraine triggering factors.
• Developmental: The middle adulthood requires multitasking, a factor that causes stress.
• Cultural: This cultural engagement might act as a safeguarding coping factor.
• Psychosocial: Good social support provides support in behavior change.
• Strengths: Has the desire and resources to achieve well-being, including the ergonomic assessment and stress-management workshops resources at the workplace.

Reflection

This complete health examination was a valuable experience to combine communication skills, clinical reasoning, and physical examination skills. The interview took place in an intimate, home office environment in a quiet location in the afternoon, which also enhanced a therapeutic and relaxed ambiance. My style focused on open-ended questions, active listening and eye contact. The interaction was consistent with the principles acquired during the course, especially the focus on holistic assessment. There was a communication barrier when the participant answered in few words about diet and stress, I managed to overcome this by using probing questions and normalizing language to get the participant to elaborate.

The examination was generally smooth, with the exception that the time needed to get a complete dietary history was higher than expected. I would in future design more organized prompts of nutrition patterns. I would have preferred to have access to previous laboratory values that would have enhanced the analysis of his cardiovascular risk. This interaction reaffirmed the use of cultural competence, therapeutic communication, and comprehensive documentation, and I will then apply them in further assessment in the future.

If you want to know more detail about this class visit: NR 304 Health Assessment II