Health history and physical assessment

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Health Assessment Assignment Presentation

NR 306 Health Assessment Assignment

1. Demographic Data

Rich (not his real name) is a 60-year old African American husband and father of four. He lives with his extended family in Bozeman Montana, where he has established a small farm where he breeds horses. He states that this is not only his current job but a hobby too. Rich is a retired Lumberjack who spent most of his younger life in the forests of British Columbia felling trees and supervising his colleagues. HE worked in the field for 30 years, after which he quit to take care of his ailing wife, who was suffering from cervical cancer. He would climb many hills felling trees while carrying a 40-pound chainsaw in 10-hour day shifts. Later on, he was promoted to a supervisor, tasked with monitoring and overseeing the work of his colleagues. After his wife’s recovery, they both decided to retire on a rural farm and established a business out of their passion. Rich. His wife was a housewife, taking care of the family and volunteering at a local children’s home on regular basis. He works out three times a week and is very particular about what he eats. He does not have any chronic condition but had hip replacement surgery two years ago. Rich does not smoke but likes to enjoy a cold beer with his friends on game nights

2. Review of Systems

The patient indicated that he has no known allergies. No physical abnormalities were observed on his skin, and he indicated no known issues. He denied experiencing any muscle weakness, fever or chill. The patient has presbyopia and has to wear glasses for correction of both short-sightedness and long-sightedness. He underwent Lasik surgery when he was 40, which corrected his myopia until he turned 55. He can read well and don’t experience any eye pains during the examination. Rich does not experience any shortness of breath or chest pain that would indicate a respiratory issue. Neither was an abnormality detected in his cardiovascular, musculoskeletal, and neurological or gastrointestinal systems. However, he indicates his struggles with an ingrown toenail which is preventing him from properly wearing a shoe. Rich is proud of his current health status and associates it with regular exercising at his age and having a proper diet.

3. Past/Family/Perception of Medical History

Rich comes from a family with a history of diabetes, but he is not affected. His wife is hypertensive but they manage the condition through diet and alternative medicine such as herbs and nutritional supplements. His mother was a chain smoker who succumbed to the complications of liver cirrhosis and diabetes. She passed away at the age of 53 after being in a coma for two weeks. Rich also has a sister, who is currently battling cystic fibrosis. She