Assignment: Subjective Medical History Assignment
Assignment Subjective Medical History Assignment
Chief Complain: The client visits the clinic complaining of “feeling like his heart is pounding or racing.”
History of Presenting Illness (HPI): Mr. X pointed out palpitations, which he reported as his heart racing two days ago. Often episodic and worsened by the slightest stressors that may lead to anxiety and relieved by meditation often carried out in his backyard. The palpitations are reported to be incidental, and he cannot trace the exact instances he has undergone over the past two days before reporting to the healthcare giver. The client is deeply concerned about his health state and opted to seek medical advice
Past Medical History (PMHx): The client has not been admitted to any hospital before; apart from the time he was involved in a Road Traffic Accident in 2009. At this time, he reports having been transfused with blood due to excessive hemorrhage. No history of primary medical conditions like Diabetes, Tuberculosis, or Cancer.
Allergies: The client is not allergic to any drugs or food as per his comprehension. He denies being allergic to latex.
Medications: The client reports having taken Amoxicillin capsules 500mg TID for the past three days and combined it with Acetaminophen 500mg PRN. He denies ever receiving any herbal medicines for fear of poisoning.
Family History (FamHx): He is the firstborn in a family of four. Two boys and two girls. All his siblings are alive and well. No history of either diabetes or cancer ever heard of as reported by the client from both the maternal and paternal side. Denies any history of psychiatric illnesses in the family too. Denies any history of twins in the family.
Personal and Social History (SocHx): The client reports to have grown up in the nearby town with loving immediate and extended families. He reports that he schooled up to undergraduate. Currently undertaking his masters at a local campus. He reports to have had a healthy childhood development devoid of traumatic experiences. He denies having disorders like sleepwalking or bed wetting and reports having attained all development milestones devoid of any traumatic events. Socially, he denies drug and substance abuse. He denies alcohol abuse. He is a Christian and does a fellowship at a nearby local church. Reports being engaged to one partner of whom he looks forward to starting a family with.
Review of Systems
General survey: the client looks wasted with fine, straight hair which is relatively well distributed and is relatively sick looking.
Integumentary: the client reports constant sensation to scratch at times; reports that the scratching is irresistible at times; evident by the scars on his left upper arm.
Head, Eyes, Ears, Nose, and Throat (HEENT): Eyes: The eyesight is well established. Eyes are well vascularized, pupils well constricted and good vision noted on both eyes. No discharge is reported or observed. Nose: The nose is patent with proper hair distribution. Has a centrally located septum. Devoid of olfactory hallucinations. Ears: symmetrical in shape, slightly budging, patent, and no hearing difficulties noted. No discharge noted. Devoid of auditory hallucinations. Nose: The nose is patent with proper hair distribution. His septum is centrally located, and he reports having not suffered from epistaxis. No olfactory hallucinations noted.
Mouth: oral hygiene is good. Well distributed teeth with no missing tooth, gag reflex present and exhibits no gustatory hallucinations. Throat: the client reports slight tightness of the throat causing labored breathing
Neck and Thyroid: enlarged thyroid visible and attested to by the client. Symmetrical in shape. Good range of motion. No jugular vein dissention; enlarged thyroid gland and lymph nodes noted.
Breasts and Auxiliary Lymph Nodes: On inspection, both breasts are seen and the nipples are devoid of any abnormalities; however, Mr. X reports he had noticed a change in size as they were enlarged. The nipples are not discharging any fluids. The breast tissue is devoid of any masses. The chest wall is moving bilaterally. Normal heart sounds are heard upon auscultation.
Respiratory: Mr. X reported breathing difficulties which have persisted over the past two days owing to the swelling of his neck.
Cardiovascular: Reports tachycardia and palpitations, which have been persistent and necessitated the quick visit to the hospital. Often episodic and worsened by the slightest stressors that may lead to anxiety and relieved by meditation often carried out in his backyard. The palpitations are reported to be incidental, and he cannot trace the exact instances he has undergone over the past two days before reporting to the healthcare giver. The client is deeply concerned about his health state and opted to seek medical advice
Peripheral vascular: he reports the swelling of his legs, which seem not to be relieved. Reports worrying swelling of the legs.
Gastrointestinal: no complaints reported
Genitourinary: on inspection, the pubic hair is well distributed. Denies any problem in the passing of urine. Denies pain during intercourse. No hemorrhoid or genital warts reported.
Genital/Reproductive System: reports the pubic hair is well distributed. The urethra is centrally located and is patent. No abnormal discharge and no pain when voiding.
Sexual Health: no abnormalities on the anatomical structure of his genitalia; has no difficulties during sexual intercourse; no erecting abnormalities; never been sexually harassed; denies being an active sexual individual; has never opted for any mode of contraception; denies history of sexually transmitted diseases in his lifetime.
Musculoskeletal: Mr. X reports slight episodic joint pains; however, not to cause any alarms and has been managing the pain with prescription OTC drugs when need be. He has a relatively good range of motion.
Neurological (must include reflexes on PE): relatively good reflexes. However, some shaking is reported and clubbing of fingers.
Hematologic: no abnormalities noted.
Endocrine: Reports enlarged tender thyroid gland. Reports a rapid pulse
Functional Assessment: he reports no self-care deficits as he does carry about his activities of daily living devoid of any hindrances. His schedule is inclusive of simultaneous school and job tasks of which he efficiently manages to strike a balance
Self-esteem/self-concept: the individual’s self-esteem does dictate their perception of individual well-being, the client, it is self-constructed, and perception one holds about oneself and responses to others. Mr. X does perceive self as a worthy individual in society and does endeavor to provide servant leadership to all who are his wing.
Activity/exercise: he often goes for walks with his dogs after work; meditates; exercises as a mode of keeping healthy and fit.
Nutritional status assessment– He looks relatively wasted with evident weight loss. He reports having lost 5 kilograms from the last assessment he took. He says having lost some appetite over the previous few days and hardly partakes in a balanced diet as the desire to eat has gradually faded.
Interpersonal relationships: he relates well with peers, family, and the community members at large. At school, he is a member of the environmental club and regularly participates in the endeavors to clean up and sensitize people about the significance of maintaining a healthy milieu
Spiritual resources: a frequent churchgoer. He is baptized at a local church in which he fellowships with family friends and the various community members.
Coping and stress management: The client reports having to take a walk, exercising, meditation, going to church and talking to his fiancé as a mode of coping with stressors in his life.
Personal habits – Denies alcohol, tobacco, street drugs. Socially, he desists from drug and substance abuse. Is a Christian and does a fellowship at a nearby local church.
Environment/Hazards: He reports living in a relatively safe environment devoid of hazards. There are proper waste disposal mechanisms and adequate lighting at home and work. The green landscape and absence of pollution do contribute to raising the hygienic standards of the community in which they reside.
Intimate partner violence: is engaged to one partner of whom he looks forward to starting a family.
Occupational health: At the local restaurant where he works, he reports that the management has put in place measures to ensure the safety of all employees is well catered for.
Perception of health: Mr. X does have good health-seeking behavior. He does take his health seriously and frequents the hospital when feeling unwell. He does try his level best to live a healthy life and does perceive his health as having all the facets of his life together inclusive of spiritual and emotional experience.
Developmental competence: he does perceive the unique role and response to situations as per people’s developmental stage and in line with their cultures. He aligns his expectations and relations as per the people around him to effectively affect change to self and all around him.
Part B
Health Promotion
Health promotion does encompass a crucial aspect in any healthcare delivery system; recommendations ought to be made for a myriad of services such as counseling, and screening for the prevalent conditions affecting the population. For Mr. X, he can engage in a myriad of health promotion activities that will ensure he leads a healthy lifestyle devoid of the complications that arise from hyperthyroidism:
- Testing for thyroid function: it is prudent for Mr. X to undergo a thyroid function test. The test predominantly measures the level of thyroid hormones present, majorly T4, and thyroid-stimulating hormone (TSH) (LeFevre, 2015). Blood tests may also be carried out in which an abnormality in findings will ascertain thyroid functionality issues rather than cancerous outcomes (“HTDS Guide”, 2019).
b). Mr. X should opt for foods with low iodine content, ingest foods rich in iron, selenium, zinc, calcium and vitamin D, and spices such as turmeric which have some anti-inflammatory properties (Whitney & Rolfes, 2018 ).
NURS 680 A
Complete Subjective Medical History Assignment
You will select a “patient” (friend or family member) on whom you will perform a complete history. For this assignment, the patient should be a healthy adult male or female age (18–65) with a single chief complaint
NOTE: DO NOT USE REAL NAMES OR INITIALS OR OTHERWISE IDENTIFY YOUR “PATIENT.\” FAILURE TO MAINTAIN PRIVACY WILL RESULT IN A FAILING SCORE.
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• The Subjective History documentation must follow the format below (see page 2).
• HPI must be presented in a paragraph, with the rest of the data, including ROS, must be presented in a “list” format.
• The health history must contain all required elements as outlined in the rubric.
• No physical exam is required for this assignment; it is to cover subjective information only.
• The assignment submission should be a single document that contains:
1. The Complete Subjective Medical History (see format on page 2)
2. A discussion of National Guidelines and ARHQ Health Promotion recommendations (according to the United States Preventative Task Force [USPTF]) appropriate to the patient interviewed.
Complete Subjective Medical History Assignment
*Follow this format
Subjective Data
• Biographic Data – Age/race/gender, occupation, language, and communication needs.
• Source – and reliability
• Chief Complaint (reason for seeking care) – make every attempt to use patient’s own words.
• History of Present Illness (HPI) – complete, clear, chronological account of events prompting patient to seek care. Use OLDCARTS or PQRST to gather data but do not include acronym in HPI. Document in paragraph format.
• Past Medical History (PMH) – childhood, adult illnesses, serious illnesses/hospitalizations, obstetric hx, immunizations, and last exam.
• Allergies, medication, food, environmental
• Medications – Rx, OTC, herbal, etc.
• Family History – Going back three generations note the following: age, health status and if applicable cause of death of each family member
• Personal and Social History – interests, support systems, occupation, highest level of education, job history, financial situation, spiritual beliefs, lifestyle (include: Tobacco, Illicit drug & ETOH use), alternative health care practices, sexual and obstetric history.
• Review of Systems (ROS) – series of questions from head to toe. Use these as headers to organize your documentation. Must be in the following order – include health promotion practices:
• General Survey
• Integumentary
• Head, Eyes, Ears, Nose, and Throat
• Neck/thyroid
• Breasts and axillary lymph nodes
• Respiratory
• Cardiovascular
• Peripheral vascular
• Gastrointestinal
• Genitourinary
• Genital/Reproductive system
• Sexual health
• Musculoskeletal
• Neurological (must include reflexes on PE)
• Hematologic
• Endocrine
• Functional assessment – include activities of daily living
• Self-esteem/self-concept
• Activity/exercise
• Sleep/rest/nutrition, include
• Nutritional status assessment- identify if patient is at risk for malnutrition or over-nutrition
• Interpersonal relationships
• Spiritual resources
• Coping and stress management
• Personal habits – alcohol, tobacco, street drugs
• Environment/Hazards
• Intimate partner violence
• Occupational health
• Perception of health
• Developmental Competence – children, pregnant women, older adult.
Week 6 Assignment 2: Complete Subjective Medical History
assignment icon Click for more options
You will select a “patient” (friend or family member) on whom you will perform a complete history.
For this assignment, the patient should be a healthy adult male or female ages (18–65) with a single chief complaint.
NOTE: DO NOT USE REAL NAMES OR INITIALS OR OTHERWISE IDENTIFY YOUR “PATIENT.\” FAILURE TO MAINTAIN PRIVACY WILL RESULT IN A FAILING SCORE.
This assignment addresses the subjective medical history of a patient only. No physical exam is required.
The health history must contain all required elements as outlined in the rubric.
The assignment submission should be a single document that contains:
The Complete Subjective Medical History (see format below)
A discussion of National Guidelines and ARHQ Health Promotion recommendations (according to the United States Preventative Task Force [USPTF]) appropriate to the patient interviewed.
The history documentation must follow the provided format. HPI must be presented in a paragraph with the rest of the data including ROS in a “list” format.
No physical exam is required for this assignment; it is to cover subjective information only.
National Guidelines and ARHQ Health Promotion Resources
• AHRQ Guide to Clinical Preventive Services (2012): Recommendations of the U.S. Preventive Services Task Force (pocket guide), a free copy can be obtained at: http://www.ahrq.gov/clinic/pocketgd.htm
• CDC Vaccine and Immunization Schedules: http://www.cdc.gov/vaccines/schedules/index.html
• Health Insurance Portability and Accountability Act (HIPAA) standards see: http://www.hhs.gov/ocr/hipaa/
• Healthy People 2020: http://www.healthypeople.gov/2020/default.aspx
• Stanford Getting Started with Breastfeeding Videos available at: http://newborns.stanford.edu/Breastfeeding/
• Abbreviations, acronyms and symbols, download from: http://med.stanford.edu/searchsm/?numgm=5&searchid=&q=approved+abbreviations&as_oq=
• A Step by Step Guide for Providing Preventive Services: A Systems Approach http://www.ahrq.gov/clinic/ppipix.htm
• American Academy of Nurse Practitioners www.aanp.org
• American Lung Association: http://lungusa.org; Register as a health care provider and use the “Lung Profiles for Professionals” for EBP guidelines.
• American Academy of Family Physicians www.aafp.org
• Agency for Healthcare Research and Quality www.ahrq.gov
• Asthma Treatment Guideline www.nhlbi.nih/gov
• Bioterrorism CDC Public Health Emergency Preparedness & Response. www.bt.cdc.gov.
• Bright Futures, Guidelines for Health Maintenance for Children. www.brightfutures.org
• Child Abuse Web Site http://www.capcsac.org/childabuse/laws.html
• Cochrane Library www.cochrane.org (An evidence based medicine repository. Abstracts are free, requires subscription for full articles but they can be ordered from the library.
• Community Guide www.thecommunityguide.org
• Diabetes Standards of Care: www.diabetes.org
• Guide to Clinical Preventive Services www.ahrq.gov/clinic/
• Health Disparities Web Site www.healthdisparities.net
• Healthy People www.health.gov/healthypeople
• Institute for Healthcare Improvement Website www.ihi.org
• Medicare Drug Program, This site offers a drug comparison of prices of specific drugs in different zip codes. Specific pharmacies are not listed www.medicare.gov.
• National Guideline Clearing House www.guideline.gov
• National Heart, Lung, & Blood Institute http://www.nhlbi.nih.gov/
• National Medical Library of Medicine www.pubmed.gov
• National Organization of Nurse Practitioner Faculties: competencies for Family Nurse Practitioners www.nonpf.com
• Online Journal of Dermatology http://dermatology.cdlib.org/
• Partnership for Anthrax Vaccine Education www.anthraxinfo.org
• State of California STD/HIV Prevention Training web site (note, they have low cost and free online and live training sessions. http://www.stdhivtraining.org/
• US Army Medical Command Guideline Website www.cs.amedd.army.mil/qmo
• VA Guideline Website www.oqp.med.va.gov/
• Western Journal of Medicine www.ewjm.com
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Assignment: Subjective Medical History Assignment Grading Rubric
| Performance Category | 100% or highest level of performance
100% 16 points |
Very good or high level of performance
88% 14 points |
Acceptable level of performance
81% 13 points |
Inadequate demonstration of expectations
68% 11 points |
Deficient level of performance
56% 9 points
|
Failing level
of performance 55% or less 0 points |
| Total Points Possible= 50 | 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points |
| Scholarliness
Demonstrates achievement of scholarly inquiry for professional and academic topics. |
Presentation of information was exceptional and included all of the following elements:
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Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three or more of the following elements
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| 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points | |
| Application of Course Knowledge
Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations |
Presentation of information was exceptional and included all of the following elements:
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Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in the all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three of the following elements
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| 10 Points | 9 Points | 6 Points | 0 Points | |||
| Interactive Dialogue
Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic. |
Demonstrated all of the following:
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Demonstrated 3 of the following:
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Demonstrated 2 of the following:
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Demonstrated 1 or less of the following:
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| 8 Points | 7 Points | 6 Points | 5 Points | 4 Points | 0 Points | |
| Grammar, Syntax, APA
Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error. |
The following was present:
AND
AND
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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| 0 Points Deducted | 5 Points Lost | |||||
| Participation
Requirements |
Demonstrated the following:
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Failed to demonstrate the following:
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| 0 Points Lost | 5 Points Lost | |||||
| Due Date Requirements | Demonstrated all of the following:
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |
Demonstrates one or less of the following.
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |