Subjective Health, Assessment Example

1) Skin/Hair/Nails

Current Symptoms: E.A. is a patient who presents with myriad symptoms, most notably a foot infection which is ruborous, without fever and with significant purulent discharge. This infection has been chronic with duration of approximately two months. The infection is distributed over the two most lateral toes on the right foot. This chronic infection has fluctuated over the last two months depending on antibiotic treatment. Patient has no known other diabetic complications such as involving her kidneys or nerves. Patient has no current hair or nail issues requiring medical attention.

Past History: The patient has a BMI of 24, non-insulin dependent diabetes and hypertension which are all important past medical data. Patient has never demonstrated foot infection of this type or severity prior to the past two months. Patient has no history of nail or hair issues requiring medical attention.

Family History: Patient has a history of obesity, diabetes and hypertension in her nuclear family. Patient does remember some issues with foot ulcers regarding her other family members but never requiring hospitalization or amputation.

Lifestyle and Health Practices: Patient is generally not active and eats a poor diet high. Despite regular podiatry visits the patient continues to have this chronic infection. It is unclear to what degree patient is compliant with foot examination and proper shoe wearing to avoid diabetic foot infections. Patient has no negative lifestyle choices which impact her hair or nails.

2) Head and Neck

Current Symptoms: Patient currently has no complaints regarding her head or neck outside of regular neck aches from work.

Past History: Patient has no relevant history to her present condition in her past.

Family History: Patient has no relevant family history.

Lifestyle and Health Practices: Patient regularly stretches her neck and does not engage in any contact activities which might injure her head or neck.

3) Eyes

Current Symptoms: Patient has no specific head or neck symptoms at this time. Patient should regularly see an ophthalmologist to check for diabetic retinopathy and cataracts. It is important that this patient in particular get regular eyes exams for diabetic retinopahy as it is a leading cause of blindness as the blood vessels in the eyes can swell, proliferate and damage the sensitive retina vital to proper vision.

Past History: Patients has no history of ophthalmological issues. This is surprising as the patient struggles with good control of blood sugar levels which has been known to negatively impact the onset and development of this condition.

Family History: Patient has a family history of eyeglass wearing to correct nearsightedness but no history of diabetes related eye issues.

Lifestyle and Health Practices: Patient has no relevant lifestyle issues regarding her eyes.

4) Ears

Current Symptoms: Patient currently has no hearing issues.

Past History: Patient has never had any hearing issues though as a child regularly had ear infections from swimming.

Family History: Patient’s family has no hearing issues outside of those associated with old age.

Lifestyle and Health Practices: Patient avoids excessively loud sounds which might injure her hearing and regularly cleans her ears to avoid ear infection.

References

Swaminatha V. Mahadevan; Gus. M. Garmel (5 July 2005). An introduction to clinical emergency medicine. Cambridge University Press.

Weber, J., Kelley, J., & Sprengel, A. (2010). Lab manual to accompany health assessment in nursing (4th ed.). Philadelphia: Lippincott.