Health History And Physical Assessment Of Random Patient

Health History And Physical Assessment Of Random Patient

GENERAL INFORMATION

Patient Name: R. H Name/Initials of Examiner: T. N

Gender: Female Source of Referral: A neighboring clinic

Source of History/Reliability: The Patient Date: June 22 2022.

PROBLEM LIST (list active and inactive diagnoses)

Ovarian cysts

Diabetes type 2 Mellitus

Hypertension

Cancer

Cardiovascular diseases

SUBJECTIVE DATA

CHIEF COMPLAINT (CC): “Urinating is burning and painful.”

HISTORY OF PRESENT ILLNESS (HPI): The client, R. H., is a 28-years old African American woman. She is presented to the clinic with burning and painful urination. The client also reports unusual urinating frequency, a strong urge to void, and minimal urine output. Her urine has a foul smell and looks cloudy. She further reports abdominal pain, which increases with the urge to urinate. The abdominal pain eases after voiding but returns with the urge to urinate again. The client also reports a high fever that reduces for about 5 hours after taking Ibuprofen. However, the fever returns as the medication wear off. The client reports experiencing these symptoms for the past three days. R. H also reports experiencing headaches occasionally, which she relieves with Tylenol. The client denies blood in the urine, vaginal discharge, pain during sex, or irritation or itching around the vulva and vagina. Denies chills, night sweats, weakness, or fatigue. She reports being sexually active. She has had one intimate partner for the past five years. Health History And Physical Assessment Of Random Patient

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PAST CHILDHOOD ILLNESSES: Seasonal asthma.

PAST MEDICAL HISTORY (PMH): Ovarian cyst diagnosed in September 2018.

PAST SURGICAL HISTORY (PSH): No surgical history.

ALLERGIES: No known drug or food allergy. The client reports a childhood allergic reaction toward pollen grains and dust.

UNTOWARD MEDICATION REACTIONS: No drug reaction history.

IMMUNIZATION STATUS: All childhood immunizations are up to date. The client received flu immunization in 2017 and COVID-19 vaccination in 2020.

SCREENING TESTS: Undergoes Pap test and mammogram annually since 2017.

FAMILY HISTORY:

Father: Alive with diabetes type 2 Mellitus (T2DM) and alcoholism history.

Paternal grandfather: Died of cardiovascular arrest at 75 years.

Paternal grandmother: Died of hypertension.

Paternal Uncle: Alive with no known health condition.

Paternal Auntie: Alive with asthma

Mother: Alive and was diagnosed with hypertension and breast cancer.

Maternal grandfather: Died of prostate cancer at 87 years.

Maternal grandmother: Alive with T2DM and hypertension.

Maternal Uncle: Alive with alcohol addiction.

Maternal auntie: Alive and verbally abusive.

Elder brother: Alive with a history of hypertension.

Younger brother: Alive with no known health condition.

Elder sister: Alive with a history of asthma.

Younger sister: Alive with substance use disorder history.

Daughter: 2yo and healthy.

The diagram below illustrates family members and their respective health conditions.

PERSONAL/SOCIAL:

The client is married and lives with her husband and their 2yo daughter in a four-bedroom mansion constructed on the city’s outskirts. She is a lawyer, and with her husband, they own a private law firm which operates in the city. Additionally, the client is a part-time student pursuing a Master’s Degree in Law. She enjoys attending to her clients and ensuring that everybody finds justice. She also mentors young ladies interested in becoming a lawyer in the future. The client is a Christian and participated actively in church activities, including singing in the choir. The client likes engaging in physical activities and spends most of her time at the gym or the swimming pool. She also likes spending leisure time with her husband and their daughter. They go out together for dinner over the weekends or on public holidays. The client denies smoking or using tobacco. The client is a social drinker and takes 3 to 4 beers when she goes out with her family over the weekend or on holidays. She also takes a glass of wine while making dinner once or twice weekly. Health History And Physical Assessment Of Random Patient

FEMALES: Her LMP was June 17, 2022. The client has a regular and light cycle of 28 days. Her menses last for three (3) days, accompanied by abdominal pain, which is more severe on the first day and mild on day three. She visits her gynaecologist once annually for a Pap test and mammogram. Gravida 1, abortions 0, age of menarche 13 years.

SEXUAL HISTORY: The client is heterosexual. She has been married and has had one sex partner for the last five years. She engages in unprotected sexual relations. She is on contraceptives.

MEDICATIONS:

Ibuprofen 1 g orally every 6 hours taken to relieve fever.

Tylenol 500 mg 2 pills orally every 6 hours taken to relieve occasional headache.

Review of Systems:

General: The client reports fever. Denies chills, night sweats, weakness, or fatigue.

Skin: She denies cracking, discolouration, or dryness.

HEAT:

Head: Denies head injuries, lesions to the scalp, head trauma, or scars.

Eyes: Denies blurred vision or double vision.

Ears: Denies hearing loss, ear drainage, or ear pain.

Nose: Denies nasal congestion. Denies difficulty with smelling food.

Throat: Denies swallowing difficulty.

Breasts: Denies breast masses or tenderness.

Respiratory: Denies wheezing sound.

Cardiovascular: Denies shortness of breath or chest tightness.

Gastrointestinal: Reports abdominal pain. Denies change in bowel movement or blood in the stool. Denies vomiting, diarrhoea, or constipation.

Genitourinary: Reports burning and painful urination, unusual urinating frequency, strong urge to void, and minimal urine output. Reports foul-smelling and cloudy urine. Denies blood in the urine, vaginal discharge, or irritation or itching around the vulva and vagina.

Peripheral Vascular: Denies numbness or tingling.

Musculoskeletal: Denies reduced motion or muscle stiffness.

Neurologic: Denies general weakness, dizziness, or memory loss.

Hematologic: Denies anaemia or other blood disorders.

Endocrine: Denies cold or heat intolerance.

Psychiatric: Denies insomnia, anxiety, or suicidal thoughts.

OBJECTIVE DATA

Physical Exam

Vital signs: T 97.4*F; B/P-128/80; HR RR 20, Pulse Ox 97%; W 120 lbs, H 63 inches; BMI score of 21.3.

General: General: The client is a 28-years old African American woman. The client looks younger than her actual age and appears to be healthy. She is well developed, properly groomed, and well-nourished. She is appropriately dressed for today’s weather and time of the year. The client is attentive throughout the clinical interview and maintains eye contact. She answers all interview questions correctly. The client sits upright during the interview and does not seem to be easily disrupted. She does not appear to be in acute distress. She is alert and oriented to events, places, times, and situation. Her self-reported mood is fantastic. Her judgment is good, and she is future-oriented. The client speaks in a low tone, and her affect is appropriate. Health History And Physical Assessment Of Random Patient

HEAT:

Head: No injuries or deformities to the scalp. Long and evenly distributed hair was noted.

Eyes: Equally round pupils and sensitive to light.

Ears: No drainage present in external auditory canals. Symmetrical bilaterally.

Nose: Turbinates not inflamed with moist and pink nasal mucosa.

Throat: Good dentition in the mouth with moist and pink oral mucosa.

Neck: No lymphadenopathy noted. Non-tender on palpation.

Chest/Lungs: No respiratory difficulty signs. No wheezing sound. Symmetrical chest expansion.

Heart/Peripheral Vascular: No murmurs, gallops, or rubs were heard. Regular heart rate and rhythm.

Abdomen: Non-distended and non-tender abdomen. Bowel sounds are heard in the four quadrants.

Genital/Rectal: No blood in the stool or urine.

Musculoskeletal: Suprapubic region was tender on palpation. Assessment of rectal and pelvic was deferred.

Neurological: Strength detected on all four extremities.

Skin: Smooth skin with no discoloration or cracks.

Diagnostic results:

Dipstick urinalysis results: Leucocyte esterase and nitrite were positive
Urine culture: Waiting for results

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ASSESSMENT

Based on health-related information provided by the client, physical examination results, and diagnostic tests, three potential diagnoses for this client, starting from the most likely to the least likely diagnosis, are listed below.

Urinary tract infection (UTI) – Primary diagnosis
Acute Pyelonephritis

Vaginitis

Overactive bladder

Primary Diagnosis

Urinary tract infection (UTI) is the primary diagnosis for this client. According to Tang et al. (2019), UTI is characterized by various clinical manifestations, including suprapubic tenderness, dysuria, urgency, frequency, painful and burning urination, a small amount of urine, and a persistent and strong urge to urinate, strong-smelling urine, and urine that appears cloudy. Upon visiting the clinic, the client reports these symptoms, including burning and painful urination, unusual urinating frequency, strong urge to void, minimal urine output, and foul-smelling urine that looks cloudy. Additionally, the client reports a high fever that reduces for about 5 hours after taking Ibuprofen. According to El-Radhi (2018), fever is a key symptom in infectious infections. A high fever indicates an infection in the body. Therefore, UTI qualifies as the primary diagnosis for this client.

Differential Diagnosis

The first differential diagnosis for this client is acute pyelonephritis. This condition is characterized by chills, fever, pain on the back, side, or groin, nausea and vomiting, dark, cloudy, bloody urine, painful and frequent urination, urgency, and foul-smelling urine (Feggi, 2018). The client qualifies for this diagnosis since she reports symptoms of this condition, including high fever, abdominal pain, painful and frequent urination, urgency, and foul-smelling urine. Nonetheless, pyelonephritis is ruled out since the client denies significant clinical manifestations, including chills, nausea and vomiting, and bloody urine.

The second potential diagnosis for this client is vaginitis. This condition is characterized by a change in odor, color, or amount of vaginal discharge; vaginal irritation, pain during sex, light vaginal bleeding, and painful urination (Baptista & Eleutério, 2020). R. H might have this disorder since she reports some symptoms attributed to vaginitis, including painful urination. However, vaginitis is ruled out since the client denies significant symptoms of this condition, including blood in the urine, vaginal discharge, pain during sex, and irritation or itching around the vulva and vagina opening.

Overactive bladder is the last differential diagnosis for this client. This condition is characterized by a sudden urge to urinate that is uncontrollable, urgency incontinence, frequent urination, usually urinating more than eight times in 24 hours, and nocturia (Raju & Linder, 2020)Health History And Physical Assessment Of Random Patient . The client qualifies for this diagnosis since she reports symptoms, including a sudden urge to urinate and frequent urination. However, an overactive bladder is ruled out in this client due to the absence of significant symptoms, including urgency incontinence and nocturia.

THE PLAN OF CARE

Treatment of Urinary tract infection (UTI) involves pharmacological and non-pharmacological interventions. Antibiotic medicines (fluoroquinolones), including ciprofloxacin (Cipro) or levofloxacin, should be prescribed to the client due to their safety and efficacy in treating bacterial infections (Cao et al., 2021). Additionally, the client should be advised to continue taking Ibuprofen to relieve fever. According to de Martino et al. (2017), Ibuprofen is effective and safe for relieving adult fever and pain. Hence, continuing Ibuprofen will relieve the client’s fever.

On the other hand, non-pharmacological treatment for this client involves patient education. The client should be advised to practice good personal hygiene. She should always put on cotton underwear and dry them completely after washing them. The client should also wipe herself front to back to avoid transmitting bacteria from the anus to the vaginal area. Furthermore, she should increase her water intake to flush bacteria out of the urinary tract. Finally, the client should empty the bladder frequently in less than three hours and ensure that all urine is emptied.

References

Baptista, P. V., & Eleutério Jr, J. (2020). Diagnosis of vaginitis: time to improve and move on. Jornal Brasileiro de Doenças Sexualmente Transmissíveis; 32(e203214):1-3. DOI: 10.5327/DST-2177-8264-20203214.

Cao, D., Shen, Y., Huang, Y., Chen, B., Chen, Z., Ai, J., … & Wei, Q. (2021). Levofloxacin versus ciprofloxacin in the treatment of urinary tract infections: Evidence-based analysis. Frontiers in pharmacology, 12, 658095. https://doi.org/10.3389/fphar.2021.658095

de Martino, M., Chiarugi, A., Boner, A., Montini, G., & de’Angelis, G. L. (2017). Working towards appropriate use of Ibuprofen in children: an evidence-based appraisal. Drugs, 77(12), 1295-1311. https://link.springer.com/article/10.1007/s40265-017-0751-z.

El-Radhi, A. S. (2018). Fever is a common infectious disease. In Clinical Manual of Fever in Children (pp. 85-140). Springer, Cham. Doi: 10.1007/978-3-319-92336-9_5.

Feggi, L. M. (2018). Acute Pyelonephritis Today. International Journal of Radiology, 5(1), 179-187. DOI:10.17554/j.issn.2313-3406.2018.05.53

Raju, R., & Linder, B. J. (2020, February). Evaluation and treatment of overactive bladder in women. Mayo Clinic Proceedings (Vol. 95, No. 2, pp. 370-377). Elsevier.

Tang, M., Quanstrom, K., Jin. C, & Suskind, A, M. (2019). Recurrent Urinary Tract Infections are Associated with Frailty in Older Adults. Urology; 123:24-27. Health History And Physical Assessment Of Random Patient

History and Physical # 2

Patient: Mr. M., 65 year old Gender: Male Date: 11/3/2017 Examiner: Carolina Munoz

Problem List:

Hypertension (1996), Active
Hyperlipidemia (1996), Active

Chief Complaint:

Follow up for right knee pain on and off for about 3 months

History of Present Illness:

Mr. M. states, “My right knee has been hurting me on and off for 3 months now.” Mr. M. describes his pain as dull and start on the side and spreads over knee. He feels the pain when he is in the gym doing leg exercises or going up the stairs. The pain remains for at least 1-2 hours after he does this activity then subsides on its own. He rates the pain as a 4/10 on a numeric scale but if he is just walking or laying down he has 0/10 pain. Mr. M. claims the pain becomes most severe when he is doing lunges and in the morning after arising. He also states the knee feels stiff in the morning but after an hour of waking up, “it feels back to normal.” Ice relieves the pain and he denies taking any over the counter medication. Mr. M. also denies any recent injury to the area.

Past medical history:

Childhood illnesses: Unknown

Adult illnesses:

Hypertension (1996)
Hyperlipidemia (1996)

Past Surgical History: Not applicable

Allergies: Mr. D.P. has no known drug, environmental or food allergies.

Immunizations:

Mr. M. states he did receive the diphtheria, pertussis and tetanus vaccines during his childhood and his last tetanus booster was administered June 2014. Mr. M. has received the hepatitis B vaccine and the MMR vaccines (measles, mumps and rubella vaccines). Lastly, Mr. D.P. receives the influenza vaccine yearly.

Screening exams and Health Maintenance:

PPD, 2014-negative
HIV, 2008-negative
Self-testicular exams, monthly-negative
Colonoscopy, 2014-negative
Annual physical with primary care provider

Medications:

Just for Men multivitamin tablet– one tablet; once a day by mouth, for health maintenance
Omega Fish Oil-one tablet; once a day by mouth, for health maintenance
Atorvastatin 40 mg tablet– one tablet; once a day by mouth, for hyperlipidemia
Losartan 50 mg tablet– one tablet; once a day by mouth, for hypertension

Family history:

Father died at age 52 due to a myocardial infarction, had hyperlipidemia and hypertension.
Mother died at age 72 due to cervical cancer, had hypertension and Rheumatoid arthritis.
Sister is 71 years old, alive with hypertension, controlled with medications.
Brother is 69 years old, alive with hypertension, diabetes mellitus type II and hyperlipidemia, controlled with medications.Health History And Physical Assessment Of Random Patient

Obstetric/Gynecologic: Not applicable

Personal and Social history:

Mr. M. is a 65 year old heterosexual Hispanic male. He works in maintenance, cleaning kitchens for the past 25 years and plans on retiring soon. Mr. M.’s highest educational level is high school. He lives with his wife in a condo in Bayside. He consumes alcohol, “Socially, about 6 eight ounce cans of beer a week.” He denies any use of tobacco, recreational drugs or prescribed medications. He also denies any use of assistive devices to get around or any help for activities of daily living.

Review of Systems:

General– overweight male, denied fatigue, negative for fever or night sweats. Denied any recent weight gain/loss or any changes in appetite.

Skin– Negative for rashes, sores or recent changes in moles. Generalized hair thinning, nails negative for clubbing or cyanosis.

Head, Eyes, Ears, Nose, Throat

Head- Negative for headaches, lightheadedness, dizziness or head injuries.

Eyes-Denies double or blurry vision, discharge or itchiness. Endorses last eye exam to be 1 year ago, no history of scotoma, flashing lights, glaucoma or cataracts. Wear glasses to read.

Ears- Hearing good, negative for tinnitus, earaches, discharge, infections or use of hearing aids.

Nose and Sinuses– Negative sinus pressure or rhinorrhea. No history of hay fever, sinus infections, epistaxis or post nasal drip.

Mouth and Throat- Denies cough, no history of sore tongue, bleeding gums, strep throat or rheumatic fever. Positive history of caries and receding gums, no dentures, last dental exam 6 months ago.

Neck- negative for lymph nodes tenderness

Breast- No lumps, discharge, tenderness

Respiratory: Denied shortness of breath. Negative for history of chronic cough, wheezing, dyspnea or pleuritic chest pain. No cyanosis noted in nail beds or lips, negative tuberculosis test, 2014.

Cardiovascular: History of hypertension, controlled with losartan 50mg tablet, once a day. Hyperlipidemia controlled with atorvastatin 40mg tablet, once a day. Denied chest pain, palpitations, syncope, or congenital heart disease. Denies use of multiple pillows to sleep.

Peripheral Vascular – No history of deep vein thrombosis, edema lower extremities, varicose veins, claudication or leg cramps. Denies tenderness or swelling of finger tips or toes during cold weather.

Gastrointestinal- Denies nausea or vomiting. No history of hepatitis, hemorrhoids, tarry stools, rectal bleeding or jaundice. Regular bowel movements, at least once a day. Denies constipation or diarrhea.

Urinary-Positive nocturia x 1. Denies dribbling, polyuria or history of UTIs. No history of dysuria or hematuria.

Genital- No history of sexual transmitted disease (last STD exam 2008). Denies testicular or scrotal pain, no history of sores or discharge from penis. Reports satisfactory sexual relations with only his wife and performs monthly testicular self-examinations. Health History And Physical Assessment Of Random Patient

Musculoskeletal- Positive right knee pain worse after exercises at gym. No history of broken bones, muscle injury or pain/stiffness in other joints. Denies gait imbalance or history of falls.

Neurologic- Endorses good memory. Negative loss of consciousness, seizures, memory changes. Denies numbness, tingling or involuntary movements. Denies changes in attention, speech or judgment.

Hematologic- No history of anemia or transfusions, negative for blood disorders. Does not bleed or bruise easily.

Endocrine- No known thyroid or diabetes conditions. Denies cold or heat intolerance. Denies polyphagia, polyuria and polydipsia.

Psychiatric- Denies history of depression, anxiety, hallucinations, mania or mood changes. Denies suicidal ideation, no history of suicidal attempts or psychiatric hospitalizations.

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Physical Exam:

Vital signs- Blood pressure: 110/68, Heart rate: 64, Respirations: 13, Temperature: 36.8 degrees Celsius, Pulse ox: 98%. Weight 160 lbs., height 5’2 and BMI 29.

General– Mr. M. is an alert and oriented x3, overweight Hispanic male. Dressed appropriate for weather, clean clothes. Appropriate facial expressions and maintains eye contact.

Skin- Color is appropriate for ethnicity, warm and dry. Negative for rashes, sores or recent changes in moles. Approximately 8 to 10 scattered 2-3 cm round and symmetric macules with regular borders located on the upper chest area. Hair soft and generalized thinning. Nails pink and intact, non-pitting negative for clubbing or cyanosis.

HEENT:

Head: Normocephalic, scalp without lesions or deformities.

Eyes: Vision 20/25 bilaterally, pupils 4mm constricting to 2mm. Sclera white and conjunctiva pink, both are moist. No swelling or tenderness noted. Extraocular movements intact. Disc margin sharp, without hemorrhages.

Ears: Wax mildly obscure tympanic membrane in right ear. Tympanic membranes with good cone of light. Acuity good to whispered voice, weber midline and AC>BC.

Nose: Nasal mucosa moist, septum midline and no sinus tenderness.

Mouth/Throat: Lips pink and moist. Tongue and uvula midline, gums moist and non-tender. No foul odor. Tonsils and pharynx non- erythematous, no exudate present.

Neck: Neck supple and easily moveable without resistance, trachea midline. Thyroid isthmus palpable, lobes not felt. No bruit auscultated.

Lymph nodes: Anterior cervical lymph nodes and posterior cervical lymph nodes soft, non-tender about 1 cm in size. Submandibular, submental, pre and post auricular, occipital, supraclavicular, axillary and epitrochlear nodes are non-palpable. Several small inguinal nodes palpated bilaterally, mobile, soft and non-tender.

Thorax and Lungs: Posterior and anterior thorax symmetrical with good excursion. Lungs are clear, vesicular and resonant bilaterally. Negative for adventitious sounds. 13 respirations per minute.

Cardiovascular: Carotid artery upstroke normal bilaterally, without bruits. Jugular venous pressure is measured as 8 cm with patient at 30 degrees. Apical impulse discrete and tapping, barely palpable in 5^th left midclavicular interspace. Negative for thrills, heart rate regular, S1 and S2, no extra heart beats, murmurs or gallops. 64 heart beats per minute.

Breasts: No masses palpated, nipples without discharge.

Abdomen: Protuberant, symmetrical, no masses palpated. Bowel sounds active in all four, no masses or tenderness noted upon light/deep palpation. Tympany upon percussion. No bruit auscultated. Liver span 7 cm in right mid clavicular lines, edge smooth, palpable. Spleen and kidneys non-palpable. No costovertebral angle tenderness, fluid waves or guarding noted. Health History And Physical Assessment Of Random Patient

Genitalia: not done; normal exam would demonstrate: External genitalia without lesions. Testicles descended bilaterally. Testes firm, non-tender, without masses or lesions. No penile lesions are noted and no discharge from urethra. Scrotum negative for induration or erythema. No hernias palpated in inguinal canals.

Rectal: not done; normal exam would demonstrate: Normal rectal sphincter tone, rectal vault negative for masses, hemorrhoids, fissures, or tenderness.

Extremities: Warm, without edema. No cyanosis, tremors or clubbing noted. Joints are non-tender, full range of motion intact, negative swelling or deformities.

Peripheral Vascular: Peripheral pulses in femoral, popliteal, anterior tibial, dorsalis pedis, brachial and radial pulses are +2 bilaterally. No pigmentation or ulcers. Temperature of upper and lower extremities are warm bilaterally. Hair present and equally distributed in upper and lower extremities bilaterally.

Musculoskeletal: No joint deformities. Right knee pain +crepitus, equal range of motion to left knee but + tenderness upon active range of motion. Good range of motion in hands, wrists, elbows, shoulders, spine, hips and ankles. Spine has full range of motion, negative for lordosis or kyphosis, mobility intact.

Neurological: Alert and cooperative.

Mental Status: Coherent thoughts, oriented to person, place and time.

Cranial Nerves: CN I to XII intact

Motor: Good muscle bulk and tone, upper and lower strength 5/5 throughout extremities.

Cerebellar: Point to point, finger to nose, heel to shin, rapid alternating movement all intact. Gait stable, negative for ataxia.

Sensory: Pinprick, light touch, position sense, vibration and stereognosis intact. Romberg negative.

Reflexes: Normal and symmetrical deep tendon reflexes +2 bilaterally in all extremities including; biceps, triceps, patellar, achilles and plantar downward. Negative Babinski bilaterally.

Psychiatric: not done; normal exam would demonstrate mental status examination results were above normal with score of 29 Health History And Physical Assessment Of Random Patient .

Laboratory date: last CBC and CMP are from December 2015 and lab values were all within normal limits. Blood pressure was well controlled and cholesterol levels were within normal range

October 2017:

x-ray of right knee- demonstrated osteoarthritis
RA Factor- negative
CBC and CMP all within normal limits
- Cholesterol: 190 mg/dl (below 200 mg/dl)
- HDL: 62 mg/dl (above 60 mg/dl)
- LDL: 156 mg/dl (below 150 mg/dl)
- Triglycerides: 169 (below 150 mg/dl)

HEALTH ASSESSMENT: N751

FORMAT AND INSTRUCTIONS FOR HISTORY AND PHYSICAL EXAM WRITE-UP

USE BATES’ GUIDE TO PHYSICAL EXAM TO HELP WITH THIS ASSIGNMENT

Written H&P and Oral Presentation-see Rubric :

The H&P must include the following: a complete history about your patient’s background, a complete review of systems, and a complete physical exam.

Include THREE differential diagnoses. Write a diagnostic summary regarding how each diagnosis was ruled in/out based on the CC/HPI, PMH/PSH, ROS, PE and the most current evidence-based practice.

The plan of care must be based on standards of practice for nurse practitioners; current references (less than 5, within the past 5 years) must be cited in APA format and a reference list must be attached

Template for H&P Write-Up

GENERAL INFORMATION

Patient Name (initials only): Name/Initials of Examiner:

Gender: Source of Referral:

Source of History/Reliability: Date:

PROBLEM LIST (list active and inactive diagnoses)

CHIEF COMPLAINT (CC): “quote patient”

HISTORY OF PRESENT ILLNESS (HPI): Presenting signs & symptoms, duration of same, pertinent history relevant to the chief complaint. Include 7 attributes—location, quality, quantity/severity, timing–including onset/duration, & frequency, setting in which it occurs, factors aggravating or relieving symptom, associated manifestations

PAST CHILDHOOD ILLNESSES: i.e. measles, mumps, rubella, varicella, scarlet fever, rheumatic fever, polio, and any other childhood illnesses such as Asthma (include dates)

PAST MEDICAL HISTORY (PMH): dates in reverse chronological order.

PAST SURGICAL HISTORY (PSH): surgical dates in reverse chronological order.

ALLERGIES: medications, OTCs, supplements, & environmental/seasonal/food allergies

UNTOWARD MEDICATION REACTIONS: include type of reaction/severity/date

IMMUNIZATION STATUS: e.g. Flu, Prevnar 13, TdaP, etc..Date must be included

SCREENING TESTS: e.g. colorectal screening, mammogram, pap test, PSA, etc…

FAMILY HISTORY: include relevant genetic risk history for living/deceased immediate relatives including grandparents, parents, siblings, children, grandchildren; for deceased relatives include cause of death and age; for sick relatives include age of onset

PERSONAL/SOCIAL: marital status, children, occupation, living arrangements, exercise, personal interests, religion, tobacco—use in pack years, if stopped smoking for how long did they smoke and when did they quit smoking; alcohol use—how many drinks/week, type of alcohol

FEMALES: LMP and relevant OB/GYN history Gravida, Para, Abortions-spontaneous vs. induced: age of menarche, menopause.

SEXUAL HISTORY: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception

MEDICATIONS: dose, route, frequency (write class of medication in parentheses): Health History And Physical Assessment Of Random Patient

Review of Systems:

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Breasts:

Respiratory:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Peripheral Vascular:

Musculoskeletal:

Neurologic:

Hematologic:

Endocrine:

Psychiatric:

This is a paper about a random patient which includes their health history and physical (it can be any patient with any condition -completely made up). The format is posted below. Please follow the format

Paper #1: First Written History and Physical: The Health History &Physical paper must include the following: a complete history of your patientâ€™s background, a complete review of systems, and a complete physical exam.

â€¢ Head-to-toe review of ALL systems
â€¢ Physical exam of the cardiovascular system
â€¢ Nutrition assessment
â€¢ Family history including a genogram.
â€¢ APA style

Paper 1 Grade Guideline:

Biographical Data
Points (Total 5) â€¢ Name (only initials), age
â€¢ Source of History (Who and reliability)

History of Present Illness 0,5 â€¢ Includes a chief complaint (Reason for seeing Care)
â€¢ Appropriate dimensions of cardinal symptom are listed – Location, Quality, Severity, Timing, Setting, chronology, aggravating/alleviating, associated manifestations)
â€¢ Incorporates elements of PMH, FH, SH that are relevant to the story (e.g. includes risk factors for CAD for patient with chest pain)
â€¢ ROS questions pertinent to the chief of complaint are included in HPI (not in ROS section) Health History And Physical Assessment Of Random Patient
â€¢ HPI narrative flows smoothly, in a logical fashion

Past Medical History 0.1 â€¢ Childhood Illness
â€¢ Accidents & Injuries
â€¢ Serious or Chronic Illness
â€¢ Hospitalizations

Past Surgical History 0.1 Includes approximate date, Surgeries, procedures, elective or non-elective, anesthesia given? What type of anesthesiaâ€”general, local etc.
Obstetric History (females) (with PMH) Use Gravida, Parity, Aborted, Livingâ€”G2P2 etc
â€¢ Last Menstrual Period

Immunizations 0.1 Childhood, Flu, Pneumonia, etc.

Allergies 0.1 Includes nature of adverse reactions

Medications 0.1 Includes dose, route and frequency for each medication
â€¢ Includes over the counter and herbal remedies

Family History 1.0
(including Genogram) â€¢ List medical conditions of parents, siblings, children, grandparents (GENOGRAM will be based on this***)
â€¢ Important diagnosis to look out: CAD, DM, HTN and Cancer
â€¢ Age at diagnosis (MI at what age? Etc), age of family members

Social History 0.5 â€¢ Occupation, Marital status
â€¢ Tobacco, Alcohol and Substance abuse; if they quit, how and when?
â€¢ Nutrition history
â€¢ Functional status (any assistive devices? Need help with ADLs?) and living situation (alone? In an assisted living?)
â€¢ Sexual Health- how do they define themselves? Are they sexually active? To whom? Any concern for HIV? STDs? Any use of protection? Health History And Physical Assessment Of Random Patient

Nutrition history
0.5 â€¢ Nutrition history

Review of System
1.5 â€¢ Body systems are evaluated: Constitutional/General, Skin, HEENT, Respiratory, Cardiovascular/Peripheral Vascular, GI, GU, Muscular, Neuro, Psych, Hematologic/Lymph, Endocrine
â€¢ Should NOT include PMH (ex. Cataracts or murmur of the heart belong in PMH, NOT ROS)
â€¢ Should NOT repeat information already in HPI
â€¢ Should NOT include Physical Exam findings
â€¢ Should INCLUDE adequate depth (be very thorough, in full sentences!)
â€¢ NO USE OF â€œNORMALâ€ is Allowed

Style 0.5 â€¢ Legible
â€¢ Not laden with spelling or grammatical errors
â€¢ Uses medical abbreviations appropriately, does not â€œcoinâ€ own abbreviations
â€¢ APA style, typed, double spaced with COVER PAGE

FORMAT TO FOLLOW (please add genogram)

GENERAL INFORMATION
Patient Name (initials only): Name/Initials of Examiner:
Gender: Source of Referral:
Source of History/Reliability: Date:

PROBLEM LIST (list active and inactive diagnoses)

CHIEF COMPLAINT (CC): â€œquote patientâ€
HISTORY OF PRESENT ILLNESS (HPI): Presenting signs & symptoms, duration of same, pertinent history relevant to the chief complaint. Include 7 attributesâ€”location, quality, quantity/severity, timing–including onset/duration, & frequency, setting in which it occurs, factors aggravating or relieving symptom, associated manifestations

PAST CHILDHOOD ILLNESSES: i.e. measles, mumps, rubella, varicella, scarlet fever, rheumatic fever, polio, and any other childhood illnesses such as Asthma (include dates) Health History And Physical Assessment Of Random Patient
PAST MEDICAL HISTORY (PMH): dates in reverse chronological order.
PAST SURGICAL HISTORY (PSH): surgical dates in reverse chronological order.

ALLERGIES: medications, OTCs, supplements, & environmental/seasonal/food allergies
UNTOWARD MEDICATION REACTIONS: include type of reaction/severity/date
IMMUNIZATION STATUS: e.g. Flu, Prevnar 13, TdaP, etc..Date must be included
SCREENING TESTS: e.g. colorectal screening, mammogram, pap test, PSA, etc…
FAMILY HISTORY: include relevant genetic risk history for living/deceased immediate relatives including grandparents, parents, siblings, children, grandchildren; for deceased relatives include cause of death and age; for sick relatives include age of onset
PERSONAL/SOCIAL: marital status, children, occupation, living arrangements, exercise, personal interests, religion, tobaccoâ€”use in pack years, if stopped smoking for how long did they smoke and when did they quit smoking; alcohol useâ€”how many drinks/week, type of alcohol
FEMALES: LMP and relevant OB/GYN history Gravida, Para, Abortions-spontaneous vs. induced: age of menarche, menopause.
SEXUAL HISTORY: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception

MEDICATIONS: dose, route, frequency (write class of medication in parentheses): Health History And Physical Assessment Of Random Patient

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Review of Systems:
General:
Skin:
HEENT:
Head:
Eyes:
Ears:
Nose:
Throat:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Peripheral Vascular:
Musculoskeletal:
Neurologic:
Hematologic:
Endocrine:
Psychiatric: Health History And Physical Assessment Of Random Patient