Name
Chamberlain University
NR-304: Health Assessment II
Prof. Name
Date
P.B. is a 56-year-old African American male, born in March in Jamaica, currently residing in New York. His primary language is English. He is 6 feet 1 inch tall and weighs 280 pounds. He is married and presented for a routine yearly checkup. He reported no present illness and defined health as the presence or absence of illness or condition. He considers himself healthy.
P.B. smokes approximately five cigarettes per day and consumes alcohol three times per week. He denied using illicit drugs. His childhood vaccinations are up to date, including a COVID-19 vaccine received in June 2021 and an influenza vaccine in October 2021. He reported no known past medical history, surgical history, or allergies. He currently takes no medications.
Regarding family history, his father passed away from cancer in 2019, and his mother died from dementia in 2018. He reported no history of skin cancer, rashes, bruising, headaches, or head injuries. He does not wear corrective lenses and denied vision changes or eye pain. He denied hearing problems, sore throats, wheezing, cough, or shortness of breath. He reported no history of cardiac irregularities, clots, leg cramps, or varicose veins. He also denied gastrointestinal or urinary symptoms.
Neurologically, he denied seizures, weakness, or strokes. Musculoskeletal history revealed occasional knee pain and stiffness during colder months but no fractures. His last prostate exam was in May 2021.
Culturally, P.B. reported a family tradition of using rum with honey to relieve symptoms of illness. He described himself as family-oriented. He does not belong to a religious organization but believes in a higher power.
According to Erikson’s psychosocial development theory, P.B. is in the Generativity vs. Stagnation stage, where individuals focus on nurturing and leaving a legacy for future generations.
The patient’s vital signs and physical examination findings are presented below.
| Category | Findings |
|---|---|
| Temperature | 98.6°F (37°C) |
| Heart Rate | 80 bpm, regular |
| Respiratory Rate | 20 per minute |
| Blood Pressure | 130/64 mmHg (Pre-hypertension) |
| O₂ Saturation | 98% |
| Pain Level | 0/10 |
| General Appearance | Normocephalic, no lesions or infestations |
| Eyes | Conjunctiva pink/moist, sclera white, pupils 3 mm, equal, reactive to light |
| Ears | No discharge, whisper test passed |
| Nose | Symmetrical, no deformities, drainage, or inflammation |
| Throat | Moist, no abnormalities |
| Neck | Thyroid and lymph nodes nonpalpable, not tender |
| Cardiovascular | Regular heartbeat, no murmurs, no edema |
| Respiratory | Lungs clear anterior/posterior, no wheezing, no accessory muscle usage |
| Neurological | Alert and oriented ×4, cranial nerves intact |
| Abdomen | Rounded, symmetrical, normal bowel sounds, no tenderness or distension |
| Musculoskeletal | ROM intact, muscle strength 4/5, steady gait |
| Peripheral Vascular | Within normal limits |
P.B. is generally healthy but classified as pre-hypertensive. To maintain and improve his health, lifestyle modifications are recommended. Specifically, he should reduce alcohol intake and quit smoking.
Research highlights that heavy alcohol consumption contributes to hypertension (Mostofsky et al., 2016). Additionally, smoking negatively impacts pulmonary function, reducing forced vital capacity, which may compromise respiratory, cardiac, and neurological health (Tantisuwat & Thaveeratitham, 2014).
Family involvement is essential in supporting lifestyle changes. Emotional and financial support, along with shared responsibility, can motivate adherence to healthier habits.
The interaction with P.B. was positive. The patient was cooperative, and the environment facilitated effective communication. I utilized skills learned in Health Assessment I and II and encountered no barriers.
What worked well was applying theoretical knowledge in practice. However, the lack of detailed family history, especially regarding grandparents, was a limitation. In the future, I would allocate additional time for patients to recall and gather detailed family medical history to enhance the assessment.
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
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
