NR 304 RUA Health History and Physical Assessment
Student Name
Chamberlain University
NR-304: Health Assessment II
Prof. Name
Date
RUA Health History and Physical Assessment
Health History: Subjective Data
Patient Overview
P.B. is a 56-year-old African American male, born in March in Jamaica, who currently resides in New York. English is his primary language. He stands 6 feet 1 inch tall and weighs approximately 280 pounds. P.B. is married and presented for a routine annual physical examination without acute complaints.
Perception of Health
P.B. defines health as the absence or presence of disease or medical conditions. He considers himself generally healthy and functional in daily activities.
Lifestyle and Habits
P.B. smokes about five cigarettes daily and consumes alcoholic beverages approximately three times per week. He denies illicit drug use. His immunization record is current, including the COVID-19 vaccine in June 2021 and the influenza vaccine in October 2021.
Medical and Family History
P.B. reports no known allergies, chronic illnesses, or prior surgeries. He takes no prescribed or over-the-counter medications. His father died of cancer in 2019, and his mother passed away from dementia in 2018. He does not have further details regarding his grandparents’ medical histories.
System Review Responses
Question and Answer Summary
| Question | Patient Response |
|---|---|
| Do you have any history of skin cancer, itching, rashes, or bruising? | No |
| Have you experienced headaches or head injuries? | No |
| Do you use glasses or contact lenses? | No, and no vision changes reported |
| Have you had any ringing in the ears, colds, or sore throat? | No |
| Any wheezing, cough, or shortness of breath? | No |
| Have you been diagnosed with heart problems such as murmurs or irregular rhythms? | No |
| Any blood clots, leg cramps, or varicose veins? | No |
| Have you noticed any changes in appetite, constipation, or rectal bleeding? | No |
| Do you have pain or burning with urination, difficulty urinating, or incontinence? | No |
| Any seizures, weakness, or history of strokes? | No |
| Have you had fractures or bone injuries? | No fractures; occasional knee stiffness in cold weather |
| When was your last prostate exam? | May 2021 |
Psychosocial Development Stage
According to Erikson’s stages of psychosocial development, P.B. is in the Generativity vs. Stagnation stage, characterized by the desire to contribute to society and create a meaningful legacy.
Cultural and Spiritual Beliefs
P.B. maintains a family tradition of using rum mixed with honey to alleviate illness symptoms. He identifies as family-oriented, with strong values shaped by his upbringing. Although unaffiliated with formal religion, he believes in a higher power.
NR 304 RUA Health History and Physical Assessment
Physical Examination: Objective Data
Vital Signs
| Vital Sign | Measurement | Interpretation |
|---|---|---|
| Temperature | 98.6°F (37°C) | Normal |
| Heart Rate | 80 bpm | Normal, regular |
| Respirations | 20/min | Normal |
| Blood Pressure | 130/64 mmHg | Prehypertensive |
| O₂ Saturation | 98% | Normal |
| Pain Scale | 0/10 | No pain reported |
General Appearance
P.B. is alert and oriented to person, place, time, and situation. He has a steady, balanced gait and appears in no acute distress.
HEENT (Head, Eyes, Ears, Nose, Throat)
- Head: Normocephalic, no lesions or infestations.
- Eyes: Conjunctiva pink and moist, sclera white, pupils equal at 3 mm, reactive to light and accommodation.
- Ears: No discharge; whisper test passed bilaterally.
- Nose: Symmetrical, without deformities, inflammation, or drainage; bilateral nasal patency.
- Throat: Moist mucous membranes, no swelling or erythema.
Neck and Lymphatics
Thyroid and lymph nodes nonpalpable and non-tender.
Cardiovascular System
Regular rhythm, no murmurs, no peripheral edema.
Respiratory System
Clear lung sounds bilaterally, no wheezes or rales, no use of accessory muscles.
Gastrointestinal System
Abdomen rounded and symmetrical, bowel sounds normal in all quadrants, no tenderness, distension, guarding, or rigidity.
Musculoskeletal System
Full range of motion in all extremities, muscle strength 4/5 bilaterally. Reports occasional knee stiffness during colder months.
Neurological System
Cranial nerves intact; patient alert and oriented ×4.
Needs Assessment
Educating patients about their health needs is essential to promote awareness and prevention of chronic conditions. While P.B. is generally healthy, his prehypertension indicates the need for proactive measures.
Recommendations
- Smoking Cessation – Consider nicotine replacement therapy and counseling.
- Alcohol Moderation – Reduce consumption to one to two drinks per week.
- Blood Pressure Monitoring – Weekly home measurements with clinical follow-up.
- Nutritional Changes – Reduce sodium intake and increase fruits, vegetables, and whole grains.
- Family Involvement – Engage family members to provide support, accountability, and motivation for lifestyle changes.
Research shows that excessive alcohol consumption contributes to hypertension (Mostofsky et al., 2016) and smoking negatively affects lung function and respiratory muscle strength (Tantisuwat & Thaveeratitham, 2014). Addressing these factors early can improve long-term cardiovascular and respiratory health.
Reflection
The interaction with P.B. was professional and comfortable, facilitated by open communication and a respectful approach. Clinical skills from prior training were effectively applied, and no significant barriers were encountered.
A limitation was the lack of detailed family health history beyond his parents. In future assessments, providing a pre-visit questionnaire could encourage patients to gather and provide more complete family health information. Overall, the assessment process was efficient, and the patient remained cooperative and engaged throughout.
References
Mostofsky, E., Mukamal, K. J., Giovannucci, E. L., Stampfer, M. J., & Rimm, E. B. (2016). Key findings on alcohol consumption and a variety of health outcomes from the Nurses’ Health Study. American Journal of Public Health, 106(9), 1586–1591. https://doi.org/10.2105/AJPH.2016.303336
NR 304 RUA Health History and Physical Assessment
Tantisuwat, A., & Thaveeratitham, P. (2014). Effects of smoking on chest expansion, lung function, and respiratory muscle strength of youths. Journal of Physical Therapy Science, 26(2), 167–170. https://doi.org/10.1589/jpts.26.167