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Health History and Physical Examination

Subjective Data

Demographic data

Name: Kerri Ross; Birth Date: 26/07/1991; Age: 25; Sex: Female; Resident: Colorado; Race: Caucasian; Language: English; Marital Status: Married; Occupation: Office Clerk; Education: University.

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The reason for care

She is overweight and at risk of being obese.

Present illness: No illness symptoms or signs.

Perception of health: Overweight.

Past medical history: Mild depression and hypertension. She is currently using lisinopril with no allergic report to the medication regimen. She is not on any therapeutic vaccines.

Family medical history: Her father has a history of hypertension and Type- 2- diabetes.

Reviews of the system: Circadian system might have encountered deleterious effects considering the sedentary lifestyle of Ross.

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Developmental considerations: Ross has significantly increased in body weight since commencing her current occupation five years ago. Majorly due to the reduction in physical exercise and changes in her eating patterns.

Cultural consideration: Caucasians have a high prevalence of hypertension, and type 2 diabetes, which is associated with obesity (Kaufer-Horwitz et al., 2015). The shift is associated with the change of cultural eating habits, especially the consumption of high-calorie and energy-dense foods.

Psychosocial consideration: Obese individuals get stigma and discrimination in the workplace and among their peers. The majority of people in society consider obese people as lazy, with poor eating habits. Stigmatization demoralizes obese individuals and lowers their self-esteem. Women have a high likelihood of developing anorexia nervosa due to depression and body dissatisfaction (Kaufer-Horwitz et al., 2015).

The presence of collaborative resources: Ross participates in community programs that give guides on obesity prevention. The programs encourage the selection of healthy foods and beverages, participation in physical activities, and the limitation of a sedentary lifestyle (Dick, 2004).

Objective Data: Physical Assessment

HEENT: No headaches, Eyes: No visual impairment or eye pain. Ears: No hearing impairment. Nose: No obstruction or epistaxis.

Neck: Her jugular venous pulse and pressure are 8cm. No history of tonsillitis.

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Respiratory system: No history of tuberculosis exposure, pneumonia, or asthma.

Cardiovascular system: She has a rapid rise to arterial pressure pulse with an increased systolic peak of the pulse. Normal S1, Paradoxical splitting of S2, low-pitched ventricular gallop, and right-sided S4.

Gastrointestinal system: No sign of gall bladder impairment, no heartburn problems. No problems with the lower GI, no use of laxatives or antacids. High-pitched bowel sounds are heard on a regular frequency.

Musculoskeletal system: Ross has had arthritis pain and knee osteoarthritis for the past seven months. Ross has gait disturbance that has resulted in the flattening of foot arches.

Peripheral vascular system: She has high murmurs of the left ventricular presystolic impulse and mild chronic ankle edema.

Needs Assessment

Ross needs to engage in community-based programs for weight management, and the selection of healthy foods and beverages. The community-based programs advocate for early screening and diagnosis of diseases related to obesity (Dick, 2004). However, Ross needs to comply with the dietary nutritional guidelines for Americans (Kaufer-Horwitz et al., 2015). Her food should contain plenty of vegetables, water, whole-grain foods, and lean meats. She should reduce intake of saturated fats, salt, sugars, and alcohol (Kaufer-Horwitz et al., 2015).


I had an open and nonjudgmental interaction with the client. The interaction was to the level I expected, especially on getting information about her psychosocial information. I faced a communication problem in selecting some words that would describe obesity in a less offensive description. I overcame the barriers by allowing the client does most of the talking. There were challenges in conducting the electrocardiogram test, which result in seeking assistance from the electrocardiogram specialist. I successfully managed to get most of the psychosocial and socioeconomic information about Ross. I wished to get information on the complete cell blood count, urinalysis, and chest radiograph. Next time I will alter my approach by inquiring about and focusing appropriately on the client’s concerns.


Dick, J. J. (2004). Weight Loss Interventions for Adult Obesity: Evidence for Practice. Worldviews on Evidence‐Based Nursing, 1(4), 209-214.

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Kaufer-Horwitz, M., Villa, M., Pedraza, J., Domínguez-García, J., Vázquez-Velázquez, V., Méndez, J. P., & Garcia-Garcia, E. (2015). Knowledge of Appropriate Foods and Beverages Needed for Weight Loss and Diet of Patients in an Obesity Clinic. European Journal of Clinical Nutrition, 69(1), 68-72.

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