HIM-FPX4610 Assessment 2 History and Physical (H&P)
Review the H&P below for a patient who presented in the emergency room with a number of issues. Pay close
attention to the present and past history, medications, allergies, social and family history, review of systems,
physician exam, and assessment and plan. Next, download the Patient History and Physical Template [DOCX]
(https://courseroom.capella.edu/courses/22777/files/3342489/download) and complete all of the following on the
template:
Select 15 common terms from the H&P.
Translate the 15 selected common terms into medical terms or abbreviations.
Spell the common and medical terms correctly.
Cite in correct APA style the references you used to perform your translation. Click Evidence and APA for
additional guidance on how to ensure your citations and references conform to APA guidelines.
Patient H&P
History of Present Illness:
This is a 54-year-old female who presented to the emergency room with a headache in the back of her head and
double vision. She also complains of being able to see only from half of her eye. These symptoms began
suddenly while she was out walking her dog about 45 minutes ago. A family member brought patient directly to
the emergency room for evaluation.
4/4/24, 3:11 PM Assessment 2 Instructions: HIM-FPX4610 – Winter 2024 – Section 39
https://courseroom.capella.edu/courses/22777/pages/assessment-2-instructions?module_item_id=1130728 3/4
Past Medical History:
1. High blood pressure.
2. High cholesterol.
3. Irregular, rapid heartbeat.
4. IBS.
5. Cholelithiasis with cholcystectomy.
Medications:
Diovan 80 mg with hydrochlorothiazide 12.5 mg daily.
Allergies:
None.
Social History:
Non-smoker, no alcohol.
Family History:
Both parents and older sibling died from a stroke. Grandparents had extensive colon polyps.
Review of Systems:
She has bilateral vision defects. Denies dizziness, weakness, or numbness. Denies shortness of breath, problems
breathing, and chest pain. Denies nausea, vomiting, and blood in stool. No bladder or bowel changes. No edema
or skin changes to arms and legs.
Physician Exam:
General: Patient appears to be a well-developed, well-nourished female. Alert and oriented to person, place,
and time.
Vital Signs: Stable.
Skin: No discoloration, no tissue breakdown.
4/4/24, 3:11 PM Assessment 2 Instructions: HIM-FPX4610 – Winter 2024 – Section 39
https://courseroom.capella.edu/courses/22777/pages/assessment-2-instructions?module_item_id=1130728 4/4
Head, Eyes, Ears, Nose, Throat: Pupils equal, round, and reactive to light; eye muscle movements are
intact.
Chest: Clear.
Heart: Irregular, rapid rhythm.
Abdomen: No guarding, some tenderness related to the IBS.
Arms and Legs: No leg swelling.
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