History and Physical

History and Physical Patient name: B.S. DOB-1/26/1987 Patient is a 24 year old Hispanic female, comfortably developed, well nourished. Appearance is neat and clean, nails and hair groomed, states she has graduated high trail and currently works as a nurses assistant, her behavior and conversation is age appropriate. Vital Signs: 98.6, pulse 68 and regular, respirations 18 liberal and nonlabored, B/P- 122/64, height 56, weight 160lbs. Neurological: She is awake, alert, orient x 3, is pleasant and cooperative, abulates independently with a steady gait. integumentary: shinny is pink, warm and dry. Several small bruises and scars are observed. Skin is total and without open areas. Head/Neck: Head is symmetrical, Neck- no JVD,no lumps, masses, or deformity palpated, Trachea midline and rises/falls with swallow, has plentiful movement without complaints of pain. Eyes: Sclera are white, PERLA, wears glasses, no lighting or drainage observed. Ears: Able to hear soft whisper without obstacle, no drainage or excess cerumen observed, denies pain, denies tinnitus. obtrude: Nares patent, denies allergies, denies sinus pain or pressure, no swelling palpated or observed.

Mouth: Mucous membranes pink and moist, tongue is midline, mucosa intact without sores or lesions, no loose or missing teeth, tonsils and uvula observed- no swelling or redness noted. Respiratory: Lungs are work bilaterally, no wheezes, rhonchi, or rhales heard. Respirations are easy, even and nonlabored, denies any dyspnea. States she has a history of asthma and takes an Albuterol inhaler as needed. cardiovascular: Heart rate 68, strong, rate and rythym regular. Bilateral pedal and radial tire pulses palpable. Cappillary refill brisk and less than 3 sec. No oedema noted. Denies any history of chest pain. Gastrointestinal: Abdomen soft, flat, non-tender, non-distended, BS + x4 quadrants, denies N/V/D. States bowels movements are regular and denies constipation. Genitourinary: Denies difficulty or pain with voids.... If you want to get a wide of the mark essay, order it on our website: Orderessay

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