Health Assessment.

Health Assessment.

 

Patient Information:

Initials, Age, Sex, Race

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CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:Health Assessment.

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Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here - such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.Health Assessment.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.Health Assessment.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.Health Assessment.

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Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

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Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.Health Assessment.

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This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.Health Assessment.

Patient Information:

M.K.42 y/o, Male

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CC: “Back pain.”

HPI: The patient is a 42-year-old AA male. He complains of a back pain which began one month ago. The pain is experienced on the lower back, and it sometimes radiates to his left leg. He describes the pain as aching sensation and gives a rating of 8 out of 10. The pain began when he started attending football training sessions as a representative of his organization. He has taken Ibuprofen every 6 hours to alleviate the pain for the last two weeks. He reports to be using a warm compress to help with his lower back pain.Health Assessment.

Current Medications: Ibuprofen 400 mg orally every 6 hours as needed for back pain (last taken 5 hours ago)

Amaryl 2 mg orally every morning (last taken this morning)

Lipitor 20 mg orally daily (last taken this morning)

Allergies: No known Allergies

PMHx: Well controlled diabetes Type 2 and high cholesterol using physical exercise, diet and medication. Vaccinated for flu in December, 2017. No surgical history.

Soc Hx: Married with 3 children, owns a plastic recycling company.

Fam Hx: Father has diabetes mellitus at 93 years. Mother died of cardiovascular disease. Elder brother diagnosed with Type 2 diabetes at 50 years.

ROS:

GENERAL:  no weight loss, fever, chills, weakness or fatigue. Had last physical examination in 2017.Health Assessment.

HEENT:  Eyes:  No visual loss, yellow sclerae, double vision or blurred vision. No head injury. Last

Ears, Nose, Throat:  No hearing loss, runny nose, sneezing, congestion or sore throat.

SKIN:  No itching or rash, color

Hair and nails: no changes in color, loss

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema. No irregular heartbeat, no murmurs

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, bowel problems, vomiting or diarrhea. No abdominal pain or blood. Negative for excess gas, bloating. Regular diet

GENITOURINARY: No burning on urination, incontinence, bleeding, flak pain or nocturia.Health Assessment.

NEUROLOGICAL:  No headache, stroke history, seizures, feet numbness, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities.

MUSCULOSKELETAL: positive to back pain, no joint pain or stiffness, no trauma, positive to back injury

HEMATOLOGIC:  No anemia, bleeding or bruising, positive to Type 2 DM, no transfusion history, heat/cold intolerance, thyroid problems

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety, desire for self/other harm, stresses, nightmares, memory loss, panic attacks, nervousness, hearing voices, mood changes, concentration problems. No recent deaths from close family or friends.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of eczema or rhinitis, asthma or hives

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Vital signs: B/P 120/70, P-80, R-20, T-98.4, BMI 33, Wt 198Lbs, HT 5’9.

General: good eye contact, relaxed and calm, well-groomed, friendly, good speech, AAOX3

Physical exam:

Hair: No breakage, evenly distributed on the scalp, shiny hair, Average texture dark brown, no infestations, dryness or alopecia

Skin: Warm, no rashes, bruises, or suspicious nevi to exposed skin. Dry, supple

Musculoskeletal: Normal thoracic, cervical and lumbar curves. Tenderness with a range of motion on lateral bending, flexion, extension, right rotation, and left rotation. Full range of motion in all joints. No swelling, radiation, or deformities. An uptight spinal column with the alignment of the shoulders, iliac crests, and skin creases below the buttocks. Positive monofilament test to left and right great toe and all metatarsals on feet (McCance et al., 2010).

Diagnostic results:

  1. Mechanical Low Back Pain: Presents aching pain around the lumbosacral area which is sometimes radiated to the legs (Bickley & Szilagyi, 2013). Diagnosed through physical assessment, simulation tests, distraction test, neurologic examination, leg lengths, calf circumferences and , back examination.
  2. Diabetic Peripheral Neuropathy (Distal Symmetric Sensorimotor Polyneuropathy): presents in burning pain often occurring at night. Diagnosis involves physical exam, filament test, quantitative sensory testinn (Won & Park, 2016).Health Assessment.

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Differential Diagnoses

  1. Coccyx Pain: relativelly persistent and severe taibone pain. Lumbosacral magnetic resonance imaging (MRI) identifies the structural anatomy associated with the lower back pain. Plain radiographs reveal fractures, dislocations, and abnormal curvatures of the sacrococcygeal. Pelvic MRI or CT scans examine the intrapelvic pathology (Bickley, & Szilagyi, 2013).
  2. Lumbar Spinal Stenosis: compression of nerves at the lumbar, narrowing of the spinal cord causing pain (Edmunds & Mayhew, 2014). Diagnosis involves x-rays, MRI, CT scan to examint the spine.physical exams and medical history is also used. They detect damanged ligaments , disks and tumor presence.
  3. Lumbar Facet Arthropathy: Diagnosed using an injection  f local aesthetic. MRI, CT scans, X-rays, bone scans and, plain radiographs as well as facet diagnosis diagnostic blocks. Flouroscopy is effective in correlating with other clinical tests.
  4. Herniated disc: cause pain in the lower back: diagnosed through physical examinatons like sensitivity to tiuch, MRIs and CT scans, and X-rays which rue out the presence of other illnesses and determine the affected nerves an ddisk region.disk cracks are identified by discograms through die injection while myelogram injects dyes to the soinal fluid to examine the nerves and spinal cord abnormalities (Bickley, & Szilagyi, 2013).
  5. Psoriatic Arthritis: causes backpain. Diagnosis involves the examination of fluid from the affected areas. It is differentiated from rheumatid arthritis through using the rheumatoid factor antibody.Health Assessment.