Nursing Paper on Health History and Physical Assessment Paper

Nursing Paper on Health History and Physical Assessment Paper

This is a paper about a random Male patient which includes their health history and physical (it can be any MALE patient with any condition -completely made up). The format is posted below. Please follow the format and attached Genogram in the paper. I’ll upload the format and another assignment that was completed for me

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

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

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Paper 1 Grade Guideline:

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

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

Past Medical History 0.1 • Childhood Illness
• Accidents & Injuries
• Serious or Chronic Illness
• Hospitalizations

Past Surgical History 0.1 Includes approximate date, Surgeries, procedures, elective or non-elective, anesthesia given? What type of anesthesia—general, local etc.
Obstetric History (females) (with PMH) Use Gravida, Parity, Aborted, Living—G2P2 etc
• 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
• Includes over the counter and herbal remedies

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

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

Nutrition history
0.5 • Nutrition history

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

Style 0.5 • Legible
• Not laden with spelling or grammatical errors
• Uses medical abbreviations appropriately, does not coin own abbreviations
• 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: Health History and Physical 
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.

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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):

Review of Systems:
General:
Skin:
HEENT:
Head:
Eyes:
Ears:
Nose:
Throat:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Peripheral Vascular:
Musculoskeletal:
Neurologic:
Hematologic:
Endocrine:
Psychiatric:

Nursing Paper on Health History and Physical Assessment Paper

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