GET A FREE QUOTE





  

  

NURS 5644 Advanced Health Assessment & Differential Diagnosis

Comprehensive Written Health History and Risk Assessment

 

Assignment Guideline

 

The purposes of this assignment are to:

  • practice your skills in developing a therapeutic partnership with your patient
  • obtain and build, in collaboration with the patient, a comprehensive health history
  • develop a comprehensive health risk assessment based on the data you have collected and analyzed

 

To complete this assignment, you will interview a volunteer patient and document a comprehensive health history, using the guideline provided. You will not perform any kind of physical examination; all data will be subjective in nature. You will analyze the data you have collected and compile a list of health problems and risk factors.

 

Your patient should be at least 50 years old and have at least one chronic health problem.

 

Use the guideline below to gather the comprehensive health history.  Your document should be formatted in a manner that is consistent with a standard medical record, rather than in essay form. Use the headings that are provided below to create an outline format, and be sure to include all the listed sections. Under each section, be sure to address all the suggested points. Do not include any of the instructions provided in this guideline. The HPI should be written in narrative format. Other sections may include bulleted points or brief statements.  The Review of Systems should follow the standard format, as illustrated in the textbook.

 

 

Reason for Visit, the chief complaint (cc): Date of History:

Patient Profile:

Patient Initials:

Age:

Gender:

Marital Status:

Ethnicity/Country of Origin/Race:

Language:

Education level:

Religion (optional):

Occupation:

Health insurance status:

Source of History and reliability of source

 

Health Status or History of Present Illness (HPI): HPI refers to the recent changes in health that led the patient to seek medical attention at this time. Describe the relevant information related to the chief complaint (symptom analysis).

 

If the patient does not present with a problem, or presents for a ‘routine’ health history, you should ask about the date of their last health assessment, and ask the patient to discuss any pending issues from the last exam (e.g. abnormal lab results, previous patient education related to diet or to exercise, advice regarding preventive health measures, etc) and to explain the current status of those issues. Ask how the patient would rate his/her health, and why. In addition, you should address any chronic illness the patient has, asking about current symptoms, adherence with diet, medication, etc. Finally, if you discover any significant positive symptoms in the Review of Systems, you should include those in the HPI, using the OLDCARTS model to gather additional information about the symptom.

 

 

OLDCARTS

Onset – When did it start? Did the problem come on sudden or insidiously? Location – Where on/in the body is the problem occurring? Radiation?

Duration – How long have you been having this problem? Have you had this problem before?

Characteristics – Description of the problem.

Aggravating or Associated Factors – Does anything accompany the problem? Is the concern related to some other event? What makes the symptom worse?

Relieving Factors – What makes it better? Home remedies, herbal, vitamins, over- the-counter, prescription medications, diet, activities

Temporal Factors – Time of Day? Consistent? When does problem come and go?

Severity – Can you rate the severity on a scale of 1 to 10? Has the problem affected you so much that you are no longer able to go to work or school? Does the problem prevent you from doing any of your regular routine activities?

 

The HPI should be written in narrative form, rather than bullet points.

Past Medical History (PMH):

 Be sure to indicate dates or ages of illnesses and procedures, if known. Write the PMH in bullet format, rather than as a narrative.

 

Childhood Illnesses:

Measles

Mumps

Rheumatic Fever

Polio

Rubella

Pertussis

Scarlet Fever

Chickenpox (varicella)

Frequent otitis media

  • Others

 

Adult Illnesses: Psychiatric Illnesses: Accidents and Injuries: Operations Transfusions:

Additional Hospitalizations:

 

Family Medical History: Include at least three generations, noting age of diagnosis or death for each illness, as known. Explain any missing data (e.g. adoption, unknown history of a relative). This section should be a genogram. Create a detailed pedigree diagram that includes all diagnoses with respective ages.

 

Allergies: (food, medication, environmental). Note how the allergy is manifested. Use bullet format.

 

Current Medications: (Includes prescribed medications, nonprescription drugs, herbal or ‘home remedies,’ vitamin/mineral supplements, medicines borrowed from family members or friends). Use bullet format, and include dosage and frequency for each medication.

 

Immunizations: Include dates or age of administration. Use bullet format.

 

Screening Tests (for Health Maintenance): Ask about the frequency of the following exams (ass appropriate for your patient), the date of the last exam, and the results. Use bullet format.

  • Physical Exam
  • Dental
  • Vision
  • Hearing
  • Mammogram (Female)
  • Pap smear (Female)
  • Digital rectal exam of prostate, PSA (male)
  • Fecal occult Blood/Fecal Immunochemical Test/colonoscopy/sigmoidoscopy
  • PPD/TB Screen
  • Other targeted screening based on occupation or other personal risk factors (Antibodies or titers related to infectious disease/immunization status, such as MMR, Hep B, Hep C, HIV, etc)

Home environment:

  • Home (age of the home, concerns about fire, stairs, adequacy of heat and cooling, pest control, space, smoker in the family, source of water, hazards such as asbestos or lead-based paint, privacy issues)
  • Usual mode(s) of transportation (driving car, walking, motorcycle, bicycle, public transport)
  • Neighborhood/Community (availability of stores, market, laundry facilities, drugstore, access to alternative transportation if needed)
  • Safety of the neighborhood

Use brief statement format.

 

Exercise and Leisure Activities:

  • Exercise (amount, time, and frequency); ideas on efficacy of exercise
  • Recreational activities
  • Amount of sun exposure

Use brief statement format.

 

 

Use of Safety Measures: Seat belts, helmets (bicyclists and motorcyclists), car seats for children, sunscreen, condoms, handrails in bathtub, etc

Use brief statement format.

 

 

Sleep Patterns: Number of hours per night, regularity of sleep patterns, use of sleep aids, attention to sleep hygiene, daytime sleepiness

 

Use brief statement format.

.

 

Nutritional Screen: Gather and document a 24-hour recall.

Known dietary restrictions

Dietary supplements used

Known risk factors for eating disorders

Risk factors for food/medication interactions

 

Weight: Stated weight and height. Perception of ideal weight, attainable weight; methods of weight management

 

Use brief statement format.

 

Family:

Members of current household (Use the table below as your format):

 

Name Gender Age Relationship Occupation or school grade Health status Other pertinent

on-going issues

             
             
             
             

 

Name and relationship of emergency contacts and contact information:

 

Occupational History: Type of work performed. Sedentary occupation. High-stress occupation. Working at heights, at/near moving objects, on slippery surfaces, in high temperatures, with electricity, with hazardous materials. Military history, including exposure to traumatic events

 

Use brief statement format.

 

Financial Status/Source of Income:

Use brief statement format.

 

 

Health Insurance Status: Use bullet or brief statement format

 

Advance Directives: Living will, Five Wishes, Power of Attorney, POLST/MOLST forms

Use bullet or brief statement format.

 

Recent Life Chan ges  or  Stressors   (divorce, new job, family illness, relocation)

Use bullet or brief statement format.

 

Patterns of Coping with Stress: including use of medications, support groups, religion, spirituality, yoga, meditation, etc.

 

Use bullet or brief statement format.

 

Screening for Possible Physical/Mental Abuse/Neglect: Use appropriate screening tools, such as HITS, from your required textbook or the asynchronous lecture on interviewing for the health history.  Document positive and negative responses to your specific screening questions.

Use bullet or brief statement format.

 

Functional Ability: (When relevant, older or disabled persons)

Activities of daily living (ADL) such as bathing, feeding, dressing)

Instrumental activities of daily living (IADL) such as shopping, cooking, doing errands

Use bullet or brief statement format

Substance Use: Ask about tobacco (including vaping), alcohol, recreational drugs. Include duration of use, frequency, amount, previous attempts to quit. Use appropriate screening tools, such as CAGE, from the required text. Document positive and negative responses to your specific screening questions.

 

Use bullet or brief statement format

Sexual History: Ask about the “Five P’s” as described in your required textbook: Partners, practices, protection, past STIs, pregnancy plans. Be sure to ask permission from the patient before asking questions, assure the patient of confidentiality, and use a non-judgmental approach, as described in your textbook.

 

Use bullet or brief statement format

 

Contraceptive History (Use the table provided below):

 

Time Period Contraceptive Type Problems? Reasons for Change
       

 

Reproductive & Gynecologic History: Women (Use bullet format, along with the provided tables):

 

Menstrual History:

Menarche                          Length                             Frequency

Amount                            LMP

Pain                                Bleeding Between Periods

Amenorrhea                       Premenstrual Symptoms

 

Gravida               Para                     Elective Abs                     Spon. Ab                        

 

Maternal Obstetrical History:

 

Gravida               Para: F       P       Elective ABs                Spon. ABs               L.C.          

 

Hx. Preg. 1 2 3 4 5
Date pg. end          
Wk. Gestation          
Month care started          
Total wt. gain          
Hrs. in labor          
Del. Type          
Place of del.          
Attendant          
Baby’s  sex          
Birth wt.          
Infant probs. *          
Maternal problems **          
Other comments          

 

  • < 5 1/2 ** Pregnancy-induced hypertension

> 9 labs.                                                                      Eclampsia

Need for resuscitation                                                Incompetent cervix

Genetic disorder                                                         Antibody incompatibility

Birth defects                                                              Rh Ng RhoGAM given?

Genital herpes

Other medical conditions

Infertility:

Perimenopausal Period:

Changes in menstrual pattern

Data of last menstrual period

Associated symptoms (hot flashes, night sweats, mood swings, difficulty sleeping, etc)

Impact on daily functioning

 

Reproductive History: Men     (Use bullet format)

 

Contraceptive Methods:   Number of Children:

Infertility:

Review of Systems (ROS):

Significant positive answers must be analyzed as symptoms and included in the History of Present Illness.

Use brief statement format, as shown in your textbook. Use headings for each system.

 

Constitutional: Fever, chills, Changes in weight, change in fit of clothes, weakness, fatigue, night sweats.

Skin: Changes in your skin, hair, nails.  Rashes, sores. Lumps, itching, pain

 

Head: Headache (Assess its chronological pattern and other attributes); Lesions

Eyes: Visual acuity, corrective measures.  Pain, burning, itching of eyes or surrounding area. Redness, tearing/watering, diplopia

Ear: Hearing acuity, corrective measures.  Tinnitus, vertigo, ear pain or feeling of fullness/pressure, ear discharge, excessive cerumen, use of swabs to clean ears, medications. Sustained exposure to loud noise

Nose and Sinuses: Rhinorrhea, nasal stuffiness, epistaxis, medications frequently used. Decreased sense of smell.

Mouth and Throat: Lesions on lips or in the mouth, dental caries, bleeding from gums, sore tongue, hoarseness, sore throat

 

Neck: Swollen glands or lumps in the neck, goiter. Pain or stiffness in the neck.

 

Breasts (applies to both male and female patients): Pain or discomfort,  lumps, discharge from the nipples, skin changes, redness. Frequency and timing of breast self-examination.

 

Chest/Respiratory/Cardiac: Pain or discomfort in the chest, palpitations, dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, wheezes. edema, cough (with description), hemoptysis

 

Gastrointestinal: Dysphagia, pain on swallowing, heartburn/indigestion, regurgitation, excessive belching, abdominal fullness after meals or inability to finish eating meals. Nausea and vomiting, abdominal pain, anorexia, excessive flatulence. Frequency of bowel movements, appearance and color of stool, constipation, diarrhea. Corrective measures for any of the above.

 

Urinary: Kidney/flank pain (pain at or below costal margin posteriorly), pain on urination,urinary urgency, urinary frequency, nocturia, urinary hesitancy/straining to void, reduced caliber and force of urinary stream, dribbling, incontinence. Color of urine, hematuria.

 

Genitalia:

Male – Discharge from penis; sores or growths on the penis; swelling or pain in the scrotum; sexually transmitted infections related questions; oral/anal sex; diarrhea, rectal bleeding, anal itching or pain, sore throat; sexual history (if not previously explored) – impotence; hypoactive sexual desire disorder

 

Female – Bleeding after intercourse or douching; pin with intercourse, vaginal discharge.

 

Peripheral Vascular: Pain in the arms and legs, swelling of the feet and legs, redness, tenderness, coldness, numbness, intermittent claudication. Any corrective measures for above.

 

Hematologic: Frequent or easy bleeding or bruising, nosebleeds, medications (e.g. aspirin, “blood  thinners;”  Vitamin  C  or  Vitamin  K  deficiency  (inadequate  diet,  malabsorption).

 

Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerance, sweating. Preference for hot or cold weather, perspiring more than others or needing more blankets, sweaters/coats more than others.

Musculoskeletal: Pains in joints and associated symptoms; swelling; limitation of motion (including limitation to activities of daily living); tenderness; warmth; redness; symptoms elsewhere associated with joint pains; backache. Muscle weakness (generalized or localized; relation to certain activities)

 

Neurologic: History of loss of consciousness, syncope/near syncope. Seizures or ‘spells.’ Weakness or paralysis of any part of the body. Tremors and other involuntary movement.  Pain. Paresthesias.

 

Mental Status and Psychiatric Symptoms: Problems or changes in orientation to time, place, and person; level of consciousness; understanding questions and responding appropriately; change in speech, grooming, or personal hygiene.  Change in sleep pattern. Getting lost when driving to a familiar place. Suicidal ideation (with appropriate follow-up questions if positive—include these in the HPI)

 

PROBLEM and RISK ASSESSMENT LIST

 

After you have obtained the comprehensive health history for your patient, review all of the data and construct a Problem and Risk Assessment List. The list should be holistic to include:

  • Firmly Established  Diagnoses (chronic diseases or current urgent needs)
  • Allergies
  • New Symptoms  (C/C,  HPI,  ROS)
  • Preventive Care  (Doing  or  Needs  to  be  Doing)
  • Abnormal Findings/Lab Data (as reported by the patient)
  • Risk Factors  related to safety, occupational exposures, genetic factors,
  • Personal Difficulties (Social, Family, Personal, Financial)
  • Educational or  Anticipatory  Guidance  Needs
  • Advance Directives
  • Deficits in Functional Status  (ADLs,  Incontinence,  Mobility)
  • Past medical history items that may impact future risks (e.g. history of chickenpox, with future risk of herpes zoster; history of gestational diabetes; history of tobacco use). For each of these you may have, in addition to a date of onset/date of identification, a date the problem was resolved.

 

Format your list as seen below. Remember that this is a list of problems or risk factors. It should not include any interventions, such as medications to be prescribed. It should not include a narrative.

 

 

Problem and Risk Assessment List

 

Problem or risk factor                Date of onset or date identified                   Date resolved