Professional Documents
Culture Documents
NURSG 2643
I. Biographical Data:
G. Last Examinations Date: Patient confirms last physical was three years ago
(2013), last dental was in November of 2015, last ECG and chest x-ray was five
years ago (2011). Patient cannot recall last hearing or vision test. Patient denies
having stool or serum cholesterol count.
“I feel healthy. I try to eat well and stay active. This way I don’t experience any
preventable limitations in my health.”
VI. Medications:
Patients grandfather (mother’s side) had multiple strokes and passed away from heart
problems. Patient’s grandmother (mother’s side) has high blood pressure. Patients
grandfather and grandmother (father’s side) died young in a car accident and experienced
no serious health issues before then. Patients mother diagnosed with melanoma, high
blood pressure and arthritis. Patients father has no known health issues at this time.
(Family tree attached)
Patient doesn’t smoke or do drugs but drinks occasionally (0-2 drinks a week). No
religious background. Patient confirms spending time with close friends or family at least
once a week. Patient received high school diploma (2013) and is a current online student
at Western Oklahoma State.
A. General Overall Health State: Currently 195 pounds, slight increase (over the past
year) due to a decline in physical activity. Patient denies fatigue,
weakness/malaise, fever, chills or night sweats.
B. Skin: Patient denies any history of skin disease such as eczema, psoriasis, and
hives, excessive moisture, dryness, pruritus, rashes, bruising, lesions, and any
pigment/color changes in moles,
C. Hair: Patient denies recent hair loss, change in texture or change in color.
F. Eyes: Patient denies wearing glasses or contacts. Patient denies eye pain, diplopia,
redness/swelling, watering, cataracts or glaucoma.
H. Nose and Sinuses: Patient denies discharge or severe/frequent cold, sinus pain,
nasal obstructions, nosebleeds, allergies, hay fever, or change in sense of smell.
I. Mouth and Throat. Patient denies mouth pain, frequent sore throats, bleeding
gums, toothaches, lesions in mouth or tongue, dysphasia, hoarseness, altered taste,
tonsillectomy or voice change.
J. Neck: Patient denies pain, lumps, swelling, goiters, enlarged/tender nodes, and
any limitation of movement.
K. Breast: Patient denies pain, unusual lumps and swelling, nipple discharge, and
rashes. No gynecomastia.
M. Respiratory System: Patient denies history of lung disease. Patient denies chest
pain with breathing, wheezing, or loud breathing, SOB, cough, sputum production
or exposure to pollution.
R. Male Genital System: Patient denies penis or testicular pain, sores or lesions.
Patient denies penile discharge, lumps or hernia. Patient performs testicular self-
examination 1-2 times a month.
S. Sexual Health: Patient is in sexual relationship. Patient uses condoms and partner
uses oral contraceptive. No change in erection or ejaculation.
X. Functional Assessment:
C. Sleep/Rest: Patient confirms 5-8 hours of sleep each night. Patient denies naps
during day or use of sleep aids.
family and is there for all of those people if they need help and he seeks help from
them when needed. Does not mind some time alone. “I don’t mind being my own
good company sometimes.”
G. Personal Habits: Patient confirms he used to smoke Cigarettes but quit two over
years ago. Patient confirms that he has smoked a few cigarettes since he quit, but
mostly uses an electronic cigarette now. Patient denies using chewing tobacco or
street drugs. Patient is 22 years old and said he’s had 5-6 drinks in the last 30
days.