K. F's Physical Assessment

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Running head: Assessment K.F.’s Health History and Physical Assessment Kimberly Genz Maryville University – St. Louis Biographic Data Client’s name: K.F. Age: 30 Race: Caucasian Religion: Jewish Usual Source of Health Care: primary (family) physician Usual State of Health: mostly healthy Insurance: UHC Occupation: student and exotic dancer Marital Status: single Current Health Status Patient states: “I’m here because I just recently saved up enough money to get health insurance this month. It has been 2 years since my last check-up. My tongue has been swollen and painful for a few weeks so I wanted to get it checked out. Also I have a rash on the inside of each of my thighs.” Patient states: “I feel fine other…show more content…
I had the chicken pox when I was 5. I got them from my brother. I had kidney stones in 2001 that had to be surgically removed. I was in the hospital for 2 days.” Patient denies allergies to any foods but says, “I am allergic to latex.” Patient was treated for urinary tract infection recently. Family Health History Patient states that grandparents on each side of her family passed away because of cancer. (see genogram on next page) Review of Systems General Symptoms – Patient complains of swollen/painful tongue and a rash on the inside of her thighs. Says pain in tongue is a 7 out of 10 when talking or eating. Integumentary – Patient describes skin as dry. Uses lotion and baby oil. No bruising or non-healing sores. Nails thin. Patient describes hair as thick and soft. Patient points out rash on inner thighs, says “it burns and itches when I…show more content…
Patient does not use protection unless non-latex condoms present. Denies pain, discomfort, or post-coital bleeding. Patient says she has never had a sexually transmitted disease. Musculoskeletal – Patient states, “I’m in pretty good shape for my age. Dancing every night is good for my flexibility.” Patient denies stiffness or joint pain. Patient says, “I have a little back pain after those long nights sometimes.” Central Nervous – Patients speech is clear. She follows verbal cues. Patient is a nursing student during the day and an exotic dancer at night. Patient states, “I know I’m not setting the best example by being a dancer, but I have to pay for school somehow.” Patient says she remembers dates, numbers, and names of people easily. Head to Toe Physical Examination General Survey - Ht: 5 foot 2 inches; Wt: 110 lb; Radial pulse: 75; Resp: 19; B/P: R Arm 110/70, L Arm 110/68; Temp: 98.6. Patient alert and oriented times 3. Patient is sitting on table with hands folded in lap and legs dangling. Patient smiles when answering questions. Patient appears nervous. Patients dress is clean. Patient shows good hygiene. Patient walks with erect

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