Health and History assessment

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Health Medical

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This assignment has two steps health assessment and power points on subject

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Assignment 2: Complete Health History and Physical Assessment You are required to complete a health history and physical assessment you should select a nonfamily member to complete this assignment. Completing the write-up: The health history and physical assessment write-up should be detailed and contain all the areas that are listed on the health and physical assessment form provided below. You should choose a patient from your practicum experience that you have completed a detailed head-to-toe assessment on. Your subjective, objective, assessment, and plan (SOAP) note may be helpful to you as you begin to write up this assignment. You will use the health and physical assessment form that is provide in next upload. Please note that the health and physical assessment form is similar to the SOAP note but has more detail included for this assignment. You will not get credit if you submit the SOAP note form instead of the health and physical assessment form provided. You are required to include a self assessment of your performance while completing the complete health history and physical assessment that includes an improvement plan for yourself. Assignment 2: Complete Health History and Physical Assessment Write-Up Presentation You were required to complete a health history and physical assessment on a patient you assessed in your practicum and submit a professional Microsoft PowerPoint presentation with narrative slides and present it this week. Completing the PowerPoint presentation with narrative slides: The health history and physical assessment presentation will utilize the detailed health history and physical assessment you completed. You are to develop a professional PowerPoint presentation with narrative slides that covers the complete health history and physical assessment. You can design your PowerPoint presentation yourself. Keep in mind that this is a professional presentation. Please remember to abide by HIPAA rules and do not display or mention your patients name on the PowerPoint slides or in your oral presentation. As you are completing your PowerPoint presentation you will need to add narrative to the slides. The narrative should be added under each slide in the PowerPoint presentation. Rubric for this Power point presentation Developed a professional PowerPoint that covers all major topics in the Health History and Physical Assessment Form. Pt 75 Include narrative for each slide (at bottom of slide) of the presentation. Pt 20 Presented the Health History and Physical Assessment in a professional manner using correct medical terminology. Pt 15 Lead discussion with appropriate answers and questions to presentation. Pt 15 Respond to at least two of your classmates with substantial responses supported by evidence based literature related to their presentation. Pt 50 Used correct spelling, grammar, and professional vocabulary. Cited all sources using the correct APA style. Pt 25 Total: Pt = 200 Health and Physical Assessment Form Name (Initials): Date: Age: Time: Sex: SUBJECTIVE Data Chief Complaint (CC): Reason given by the patient for seeking medical care “in quotes” History of Present Illness (HPI): Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Include the 7 attributes of the symptoms: Location, quality, quantity/sverity, timing, remitting/exacerbating, factors, associated manifestations. Medications: (Name of the medication, route, dosage, and reason for med ) Medication Intolerances: Past Medical History (PMH) Allergies (Drugs, Food, and Environmental): Tobacco, alcohol, or illicit drug use in the past: Chronic Illnesses/Major traumas: History of any illness: Childhood: Adult: Ob/Gyn: Psychiatric: Hospitalizations/Surgeries: “Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.” Record illness from childhood through current time. Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Develop a genogram to show a representation of the family history. Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety statu. Did you perform any assessments for these areas?If elderly, do they have rugs on the floor or poor lighting, etc?. Do they have money for food, medications, etc.? ROS General Cardiovascular Weight change, fatigue, fever, chills, night sweats, energy level Chest pain, palpitations, PND, orthopnea, edema Skin Respiratory Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB Eyes Gastrointestinal Corrective lenses, blurring, visual changes of any kind Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears Genitourinary/Gynecological Ear pain, hearing loss, ringing in ears, discharge Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Musculoskeletal Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Breast Neurological SBE, lumps, bumps or changes Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Psychiatric Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx OBJECTIVE Data Weight BMI Height General Appearance Temp Pulse BP Resp Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. Skin Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. ) (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests Urinalysis – pending Urine culture – pending Wet prep - pending Special Tests Differential Diagnoses and Diagnosis Differential Diagnoses o o o 123- Final Diagnosis: Plan/Therapeutics o Plan:      Further testing Medication Education Non-medication treatments Return to clinic when? Evaluation of patient encounter Give a summary of your patient experience/encounter. What were your weaknesses as you interviewed and assessed the patient? What were your strengths? How would you prepare differently as you progress and grow as a Nurse Practitioner?
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Attached.

Health and Physical Assessment

Details of the Assessment
O Date: 22rd Feb 2017
O Age: 72
O Sex: MALE
O Time: 08:00AM

Chief Complaint (CC):
• “The patient complains of chest discomfort. This is

discomfort majorly in the center of the chest a lasts
for few minutes” “ this trouble comes in the form
of pain, uncomfortable pressure and squeezing”
• “The patient is complaining of upper body
discomfort which entails discomfort or pain in one
arm, jaw, back or the stomach.”
• “He has experienced shortness of breath which
tends to occur before or during chest pain”
• “Other complaints are that he experiences nausea
and rapid sweating.”

History of Present Illness (HPI
O The disease started two weeks ago, the situation getting

worse each day and the patient did not visit any health
care facility to report the disease, the symptoms seem to
discomfort in the chest region and the abdomen majorly.
O The patient started experiencing breathlessness swelling
in legs, ankles, and feet.
O There are no alleviating factors, but there are
aggravating factors such as hypertension. Other
pertinent negatives include peptic ulcer disease and
pneumonia.
O The patient had been diagnosed with lipid disorder
earlier, but there were no diagnostic testing that was
related to the current illness done

Medications and Medication
Intolerances::
O These medications are for treatment of heart

failure in early stages to prevent further damage to
the heart.
O They include drugs like Angiotensin-2 to halt fluid
accumulation in body tissues and use of Thiazide
diuretics to lower blood pressure.
O The patient should take 10mg daily of each drug
O Medication intolerance entails an adverse reaction
of the patient towards any medicine. The patient
has medical intolerances to some antibiotics which
include penicillin and amoxicillin

Past Medical History (PMH)
Allergies (Drugs, Food, and
Environmental):
O The patient is allergic to drugs such as

penicillin and amoxicillin; he is also allergic to
pork and any related products.
Environmentally the patient is highly allergic
to pollen
O Tobacco, alcohol, or illicit drug use in the past:
O The patient has been smoking since his early
20s with the average consumption of alcohol.
O He has engaged in use of any illicit or hard
drug

Chronic Illnesses/Major
traumas
O The major traumas that the patient suffers are

three major gunshots on his upper limb that
have affected his walking.
O Though they do not affect his ability to walk
independently, the patient cannot walk for long
distance.

History of any illness:
O

Childhood:
The major injuries that the patient suffers are three major gunshots on his upper limb that have affected his
walking. Though they do not affect his ability to walk independently, the patient cannot walk for long
distance.
O
Adult:
The patient at the age of 50 was diagnosed with lipid disorder. The disorder has been prevailing up to the
date of this assessment. Until recently, he has not been diagnosed with any other major illness.
O
Ob/Gyn:
There are no cases of obstetrics or gynecology since the patient is a male
O
Psychiatric:
After the patient had been attacked by armed individuals who shot him severely on his legs, he was
hospitalized for some time. He developed depression about his security and the intentions of the armed
bandits. He was also stressed whether he would walk again. The psychiatric report, however, showed that
the patient managed to get over his situation and state of reasonable conduct was reported
O
Hospitalizations/Surgeries:
The patient has been hospitalized and had surgery on his left limb due to gun shots. He has been diagnosed
with asthma at the age of 10 and 12. Lipid disorder has been prevailing since the patient was 55 years
through current time.

Social History
O The patient is a certified accountant holding a degree in

accounting. He is a prosperous employee having worked for five
organizations during his career days.
O During the occupation period, the patient has risen to high
positions and ranks within the organizations he has ever worked.
He lives a middle-class life with his wife and two children.
O He has been a smoking tobacco since his teenage and
consumption of alcohol. The patient lives in a safe neighborhood;
upon an assessment of the patient’s home, it looks neat though
there are a lot of cigarettes remains in the garbage pit.
O The patient is financially well since he receives pension payment
from his previous employer. Hence he is capable of financing for
hid food and medication among other expenses

ROS
O General

The weight of the patient is increasing with the patient
experiencing fatigue, especially on arms and legs. There
are night sweats and reduction of energy level on the
patient
O Cardiovascular
The patient is experiencing chest pain
O Skin
Delayed healing, rashes, bruising, availability...


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