Health Screening and History of Older Adult
Health Screening and History of an Older Adult
Kimberly Owens
Grand Canyon University: NRS 434V (0102)
June 28, 2014
Health Screening and History of an Older Adult
Biographical Data
Client Initials J.H.
Age: 78 years old
Sex: Male
Occupation: Retired Professor
Health History and Review of Systems
Past Medical history includes : Essential Hypertension, Cardiac pacemaker, Coronary Artery Disease, Dyspnea, Sensiosenural hearing loss, Restless legs, headache, acute hypothyroidism due to radiation, Mandible Cancer, Pseudophakia of both eyes, Posterior vitreous detachment, malnutrition, Generalized weakness, Smoker of 2 packs of cigarettes per day for 30 years.
J.H. s is a 78 y.o. male with a history of moderately differentiated SCC of the left mandible. This was diagnosed in October 2013. There was some delay on the patient’s behalf on scheduling the surgery. He then had a sync opal episode and was found to have severe bradycardia and junctional bradycardia. He underwent a CABG X4 for 3 vessel disease and pacemaker placement on 11/10/2013. He underwent a left marginal mandibulectomy and left neck dissections of level 1-4 on 01/23/2014. Pathology reported grade 2 moderately differentiated SCC nodes were positive. Patient declined adjuvant therapy. Patient did well until June when he developed an infection in the hardware. He was taken back to surgery 02/10/2014 for removal of hardware and biopsy of the left cheek and mass, which was found to be invasive cancer. He then agreed to radiation and chemotherapy, which has since started. Since he develop issues with dysphagia during therapy, and a peg tube placement was recommended. He underwent a successful placement of a peg tube on 4/05/14.
Physical Examination
BP 166/73 | Pulse 69 | Temp 96.9 °F (oral) | Resp 14 | SpO2 99% on room air
General appearance: alert and oriented x 3, cooperative, no distress
Head: Normal
Eyes: Cataract surgery 5 years ago; slightly red
Kimberly Owens
Grand Canyon University: NRS 434V (0102)
June 28, 2014
Health Screening and History of an Older Adult
Biographical Data
Client Initials J.H.
Age: 78 years old
Sex: Male
Occupation: Retired Professor
Health History and Review of Systems
Past Medical history includes : Essential Hypertension, Cardiac pacemaker, Coronary Artery Disease, Dyspnea, Sensiosenural hearing loss, Restless legs, headache, acute hypothyroidism due to radiation, Mandible Cancer, Pseudophakia of both eyes, Posterior vitreous detachment, malnutrition, Generalized weakness, Smoker of 2 packs of cigarettes per day for 30 years.
J.H. s is a 78 y.o. male with a history of moderately differentiated SCC of the left mandible. This was diagnosed in October 2013. There was some delay on the patient’s behalf on scheduling the surgery. He then had a sync opal episode and was found to have severe bradycardia and junctional bradycardia. He underwent a CABG X4 for 3 vessel disease and pacemaker placement on 11/10/2013. He underwent a left marginal mandibulectomy and left neck dissections of level 1-4 on 01/23/2014. Pathology reported grade 2 moderately differentiated SCC nodes were positive. Patient declined adjuvant therapy. Patient did well until June when he developed an infection in the hardware. He was taken back to surgery 02/10/2014 for removal of hardware and biopsy of the left cheek and mass, which was found to be invasive cancer. He then agreed to radiation and chemotherapy, which has since started. Since he develop issues with dysphagia during therapy, and a peg tube placement was recommended. He underwent a successful placement of a peg tube on 4/05/14.
Physical Examination
BP 166/73 | Pulse 69 | Temp 96.9 °F (oral) | Resp 14 | SpO2 99% on room air
General appearance: alert and oriented x 3, cooperative, no distress
Head: Normal
Eyes: Cataract surgery 5 years ago; slightly red
References: Gulanick, M., Myers, J.,; Nursing Care Plans: Nursing Diagnosis and Intervention, (2012) Jarvis, C., Physical Examination and health assessment, (2012) www.cancer.org www.mcw.edu – Center for Health Communities (414) 456-8291 A Cancer support group meets the first Tuesday of every month at Froedtert and Medical College. 9000 w. Wisconsin