HEALTH HISTORY AND EXAMINATION
OF AN OLDER ADULT

HEALTH HISTORY AND EXAMINATION OF AN OLDER ADULT On March 1, 2016, with the permission of Mr. P.F. henceforth known as the client, a health history assessment and physical examination was conducted and the detailed results dictated within the appropriate assessment templates which are attached for review. In an effort to summarize the health history assessment and physical examination, the summarized assessment findings will be henceforth reported in SBAR format.
Situation
The client is a Caucasian 64 year old male, whom is alert and oriented to person, place and time whom presents as a well-groomed, well- rested, and well-nourished man that looks his age. English is spoken fluently by the client and is reported as his first language therefore interpreter services were not required. The client states that he worked and supported his family over forty years as a truck driver however has been retired since 2012. Additionally he reports living alone in a single story home which he has owned for over forty years. His plans are to continue to live in his home as long as he is able to care for himself and continue to maintain the home independently. He further states that he is able to complete all his activities of daily living independently, routinely cooks for himself three cardiac meals per day, and takes walks daily for exercise. Client does not report to currently be in a relationship or sexuality active, however did state that he had been married three times and all three wives died of natural causes. He has three living children, whom live locally and visit him frequently. He reports a strong support system not only through his children but in addition he attends church locally and has many friends there. Additionally, he stated that he was very happy because in October he will be welcoming his first great grandchild as his granddaughter is going to have her first baby.
Background
Health history is reported as uneventful during childhood other than minor childhood illnesses and a reported break to his left foot while playing football during high school years. Additionally client verbalizes all vaccinations are current including his pneumococcal and influenza vaccination which he received in October 2015 during a routine visit to his primary care physician. Health history reveals client was diagnosed with Restless Leg Syndrome (RLS) while in his 40’s and subsequently placed on Mirapex 1.5 mg QHS which per client has treated his RLS adequately. Client also reports seasonal allergies, onset date unknown, which currently are adequately controlled with over the counter Singular 1 tab per day. It is reported that both clients RLS and allergies are treated and maintained by his primary care physician. In 2015 the client had significant cardiovascular events which required medical interventions. Client was diagnosed with Atrial Fibrillation while an inpatient for chest pain. Subsequent cardioversion intervention was successful producing a normal sinus rhythm. Client was discharged to home however suffered a Myocardial Infarction the following day requiring stent placement. Client reports he was informed he had what was called the “widow maker.” Additionally, he was informed he had Hypertension and was placed on Lisinopril 5mg once daily which he routinely takes to control his blood pressure. Client reports no further chest pain and routinely follows up with his Cardiologist. Client states that the only physical ailment not managed at this time is his pain to right knee which he is currently waiting for the 2nd knee replacement to increase the range of motion and decrease his pain. First right knee replacement is reported as occurring in 2012 due to occupational wear he required surgical intervention of a complete right knee replacement. No surgical complications reported however, 100% restoration of right knee range of motion was not achieved. Client verbalizes ability to function with limited range of motion in the right knee and without durable equipment to date, however the increased amount of pain has now required him to be placed on pain medication pending a second right knee replacement which he is currently awaiting. Medication reported for pain to right knee by client is Norco 7.5/325mg which is prescribed every 4-6 hours. During physical assessment the client did report break through pain of which he has no other medication prescribed at this time specifically for break through pain.
Assessment
Comprehensive physical examination completed with findings concurring with reported health history by client. Negative abnormal findings within the following systems: Neurological, Lymphatic, Head and Neck, Nose, Skin, Thorax and Lungs, and Gastrointestinal system. Assessment of the clients Eyes, Ear and Mouth produced minimal abnormalities which do not interfere with client’s daily living. Visualization by client scored 20/20 however client reports use of reading glasses which were suggested during yearly eye check-up. The client also reported a decline in his hearing in his left ear which he stated was an occupational side effect which does not require a hearing aid nor negatively impacts his life. In addition during visualization of the client’s mouth three missing teeth were noted, however the client verbalizes that he is able to continue to chew his food correctly and it does not interfere with his dentation. Assessment of the client’s peripheral vascular system and cardiovascular system was abnormal due to the clients reported existing health conditions Restless Leg Syndrome, history of Atrial Fibrillation, Myocardial Infarction with stent placement and Hypertension. Client is negative for swelling and redness to lower extremities additionally negative for chest pain, shortness of breath, extra heart sounds or murmurs. Musculoskeletal system assessment abnormal due to right knee reported dull achy pain with limited range of motion. Client reports waiting for his second right knee replacement and currently is on pain medication however client indicates break though pain increasing in occurrence and duration. Right knee is negative for redness and swelling which would indicate a DVT. Otherwise, musculoskeletal system is normal without evidence of swelling, masses, pain and deformity bilaterally. Recommendation Client is a 64 year old male whom is currently awaiting his second corrective right knee surgical intervention. However, client is having increased episodes of break through pain with no prescribed break through pain medication ordered. Currently his prescribed pain management therapy is Norco 7.5/325 mg every 4-6hours. Recommendation for this client considering his age and comorbidities would be to only add an anti-inflammatory to his pain management regimen. Adding a narcotic or an increase to his Norco dose could increase his risk for falls and complicating his current health situation. Durable medical equipment prescription is recommended for use of a cane and walker pending surgical procedure due to increased risk of falls. Additionally, recommendation for follow up with his primary care physician to further assess for a deep vein thrombosis although this is highly thought to be negative as a physical examination indicated negative for DVT. Client’s primary care provider can in addition refer the client for physical therapy in which ultrasound therapy may prove to be beneficial at this time as the client waits for surgery of the right knee. Otherwise, further recommendation would be to continue to follow up with client’s cardiologist and general health care providers as indicated. Client should continue to take all medications as prescribed and continue to stay current on his yearly vaccinations.

References
Edelman, Carole, Kudzma, E., Mandle, C. (2014). Health Promotion Throughout the Life Span, 8th Edition. [VitalSource Bookshelf Online]. Retrieved from https://pageburstls.elsevier.com/#/books/978-0-323-09141-1/ Jarvis, C. 2012. Physical Examination and Health Assessment, 6th Edition. VitalSource Bookshelf Online. Retrieved from https://pageburstls.elsevier.com/#/books/978-1-4377-0151-7/cfi/0