Week 6 Assignment 2: Complete Subjective Medical History
Week 6 Assignment 2: Complete Subjective Medical History
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.
• 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
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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:
• 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
I would like to have the chief complain as 28 year old with palpitations.
The diagnosis will by hyperthyrodism
