Develop a history and physical (H&P) examination for the fictitious patient chosen. In previous courses in the program, you have used this subjective, objective, assessment, and plan fo
For this assignment, create a fictitious patient within the population you selected for the assignment in Topic 4 and complete the three parts of the assignment for your patient, as outlined below.
Part 1: Risk Factors, Quality Indicators, and CAM:
Identify the following regarding the health of your fictitious patient:
Risk factors associated with the patient’s demographics.
Complementary and alternative medicines (CAM).
Quality indicators specific to the patient.
Part 2: History and Physical
Develop a history and physical (H&P) examination for the fictitious patient chosen. In previous courses in the program, you have used this subjective, objective, assessment, and plan format to document H&P examinations. Refer to the “History and Physical Note” template to complete this assignment.
Part 3: Model or Plan of Care
Develop a model or plan of care for the patient population pertinent to the above-mentioned patient. This could include community or health system programs as an approach or what seems appropriate. Incorporate the 6 components of the chronic care model in your model or plan of care.
Self-management support
Community resources
Health system
Delivery system design
Decision support
Clinical information systems
General Requirements
You are required to cite three to five sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
History and Physical Note Template
Chief Complaint or Reason for Consult: Why the patient is seeking medical care or the reason you have been consulted.
History of Present Illness (HPI): History of present Illness is the who, what, when, where, why, how, how long section documenting the patients story related to the chief complaint or consult.
Past Medical History: A list of all medical diagnoses (include pertinent information such as a new diagnosis). Identify the length of the diagnosis with either year or longevity.
Past Surgical History: A list of all surgeries. Be sure to include the date of the surgery.
Family History: First degree pedigree medical diagnoses; be sure to include age and cause of death of the family member.
Social History: A synopsis of work, tobacco, alcohol, drug use, marital status, residence, travel, functional status, and surrogate/advanced directives.
Allergies: A list of medication or food allergies and the type of reaction the patient experiences when exposed to the foods or medications.
Home Medications: List all home medications and the dosage in milligrams and frequency. Document adherence, including prn/over the counter and how often the patient takes prn medications.
Hospital Medications: List the name, milligrams, frequency, and route if you are seeing the patient after being admitted.
Review of Systems: Review of symptoms (told by the patient or family) but organized by system. Must have 12 systems with at least 2 pertinent +/-
CONSTITUTIONAL: These are patients answers about general constitutional signs or symptoms. Some examples may be fatigue, exercise intolerance, fever, weakness, and impaired ability to carry out functions of daily living.
EYES: These are the patients answers about signs or symptoms that may include the use of glasses, eye discharge, eyes itching, tearing or pain, spots or floaters, blurred or doubled vision, twitching, light sensitivity, swelling around the eyes or lids, and visual disturbances.
EARS, NOSE, and THROAT: These are the patients answers about signs or symptoms including sensitivity to noise, ear pain, ringing in the ears, vertigo, feeling of fullness in the ears, ear wax, and abnormalities. It could include nosebleed, postnasal drip, frequent sneezing, frequent nasal drainage, impaired ability to smell, sinus pain, difficulty breathing, history of sinus infection and treatment. For the throat and mouth, sore throat, current or recurrent mouth lesions, teeth sensitivity, bleeding gums, history of hoarseness, change in voice quality, difficulty in swallowing, or inability to taste.
CARDIOVASCULAR: These are the patient’s answers regarding signs and symptoms that may include chest pain, tightness, numbness, palpitations, heart murmurs, irregular pulse, color changes in the fingers or toes, edema, or leg pain when walking.
RESPIRATORY: These are the patients answers about signs or symptoms of the respiratory system. Some examples may include cough, phlegm, chest pain on deep inhalation, wheezing, or shortness of breath, difficulty breathing.
GASTROINTESTINAL: These are the patients answers about signs or symptoms of the GI system and include such things as indigestion or pain associated with eating, burning sensation in the esophagus, frequent nausea or vomiting, abdominal swelling, or changes in bowel habits or stool characteristics such as diarrhea or constipation.
GENITOURINARY: These are the patients answers about signs or symptoms of the genitourinary system. Some examples include painful urination, urine characteristics, urinary patterns, hesitance, flank pain, decreased or increased output, dribbling, incontinence, frequency at night, genital sores, erectile dysfunction, irregular menses, toilet training, or bedwetting.
MUSCULOSKELETAL: These are the patients answers about signs or symptoms of the musculoskeletal system. Examples include muscle cramps, twitching or pain, limitations on walking, running, or participation in sports, joint swelling, redness or pain, joint deformities, stiffness, or noise with joint movement.
INTEGUMENTARY: These are the patients answers about signs or symptoms of the skin. Some examples may be itching; rash; skin reactions to hot and cold; changes of scars, moles, sores, lesion, nail color or texture; breast pain, tenderness or swelling; or breast lumps and history of nipple discharge or changes.
NEUROLOGICAL: These are patients answers about signs or symptoms of the neurologic system. Examples include numbness, tingling, dizziness, fainting or unconsciousness, seizures or convulsions, memory loss, attention difficulties, hallucinations, disorientation, speech or language dysfunction, inability to concentrate, sensory disturbances, motor disturbances, including gait, balance, and coordination, tremor, or paralysis.
PSYCHIATRIC: These are patients answers about signs or symptoms of the psychiatric system. Some examples include depression, excessive worrying, stress, suicidal thoughts, persistent sadness, anxiety, loss of pleasure from usual activities, loss of energy, physical problems that do not respond to treatment, restlessness, irritability, or excessive mood swings.
ENDOCRINE: These are the patients answers about signs or symptoms of the endocrine system. Some examples include blood sugar readings at home, sudden changes in height or weight, increased appetite or thirst, intolerance to heat or cold, or changes in hair distribution or skin pigment.
HEMATOLOGIC/LYMPHATIC: These are the patients answers about signs or symptoms of the hematologic/lymphatic system. Examples include easy bruising, fevers that come and go, swollen glands, night sweats, and unusual bleeding.
ALLERGIC/IMMUNOLOGIC: These are the patients answers about signs or symptoms of allergic/immunologic issues. Examples include allergies to medication, foods, or other substances; hives and/or itching; frequent sneezing; chronic or clear postnasal drip; conjunctivitis; or history of chronic infection.
Physical Exam: What you identify as you assess the patient.
GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress.
VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal cannula, weight, and BMI.
HEENT: Normocephalic and atraumatic. No scleral icterus. Pupils are equal, round, and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good dentition, no lesions. Tympanic membranes are clear.
NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness.
CHEST: Symmetric. Nontender to palpation.
LUNGS: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi, or rales.
HEART: Regular rate and rhythm with normal S1 and S2. No murmurs, gallops, or rubs.
BREASTS: Symmetrical. No skin or nipple retractions. No nipple discharges or masses.
ABDOMEN: Soft, flat, and benign. No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass.
GENITOURINARY: [Male]. The phallus is circumcised. There are no penile plaques or genital skin lesions. The glans is normal. The meatus is orthotopic, patent, and clear. The testicles are descended bilaterally without masses or tenderness. The epididymis and cords are normal. The perineum is normal.
GENITOURINARY: [Female]. External genitalia normal. Vagina and cervix without lesions or masses. Uterus is normal. Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus are normal.
RECTAL: [Male]. Normal sphincter tone. No masses. Prostate is smooth and nontender and without nodules or fluctuance.
RECTAL: [Female]. Normal sphincter tone. No masses or tenderness.
EXTREMITIES: No cyanosis, clubbing, or edema.
NEUROLOGIC: No focal sensory or motor deficits are noted. Gait is normal. Cranial nerves II through XII are intact. Deep tendon reflexes are intact.
PSYCHIATRIC: The patient is awake, alert, and oriented x3. Recent and remote memory is intact. Appropriate mood and affect.
SKIN: Warm, dry, and well perfused. Good turgor. No lesions, nodules, or rashes are noted. No onychomycosis. Address surgical wounds and drains.
LYMPHATICS: No cervical, axillary, or groin adenopathy is noted.
Laboratory and Radiology Results: List all data available when seeing the patient’s normal and abnormal results. Include all of the CBC and electrolytes (all elements tell a story).
Lab Diagnostic Work-Up that may be needed
Differential Diagnosis:
Provide at least three possible differential diagnoses based on clinical practice guidelines. Review the videos in the topic Resources for support on this part of the assignment.
Geriatric or Ethical Considerations:
Based on the age or current state of health, address any differences in the treatment to reflect projected patient outcomes.
References: List references in APA format.
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