Assignment: Writing Patient Report

Assignment: Writing Patient Report

 

Question 1

A patient reports “something flew in my eye” about an hour ago while he was splitting logs. If there were a foreign body in his eye, the nurse practitioner would expect to find all except:

Question 2

Your well-nourished 75-year-old patient has come into the office for a physical exam and states that she recently had two nosebleeds. She does not take any anticoagulants, and you have ruled out any coagulopathies. The most likely cause of these nosebleeds is:

Question 3

Mark has just been given a diagnosis of congestive heart failure. Which of his medications should be discontinued?

Question 5

Which of the following is the most important diagnosis to rule out in the adult patient with acute bronchitis?

Question 6

Risk factors for acute arterial insufficiency include which of the following?

Question 7

What is the Gold standard for the diagnosis of asthma?

Question 8

Which of the following dermatologic vehicles are the most effective in absorbing moisture and decreasing friction?

Question 9

Amaurosis fugax is described as a:

Question 10

Jennifer, age 49, who has a history of hyperlipidemia, has symptoms that lead you to suspect unstable angina. Your next action would be to:

Question 11

Which of the following patient characteristics are associated with chronic bronchitis?

Question 13

John, age 59, presents with recurrent, sharply circumscribed red papules and plaques with a powdery white scale on the extensor aspect of his elbows and knees. What do you suspect?

Question 14

A 2 year old presents with a white pupillary reflex. What is the most likely cause of this finding?

Question 15

Expected spirometry readings when the patient has chronic emphysema include:

Question 16

Larry, age 66, is a smoker with hyperlipidemia and hypertension. He is 6 months post-MI. To prevent reinfarction, the most important behavior change that he can make is to:

Question 17

A 58-year-old man is diagnosed with Barrett’s esophagus after an endoscopy. He has no known allergies. Which of the following medications is MOST appropriate to treat this patient’s disorder?

Question 18

A 57-year-old male presents to urgent care complaining of substernal chest discomfort for the past hour. The EKG reveals ST elevations in Leads II, III, and AVF. The nurse practitioner is aware that these changes are consistent with which myocardial infarction territory?

Question 19

A patient presents with periorbital erythema and edema, fever, and nasal drainage. The nurse practitioner should:

Question 20

An employee picnic menu includes grilled hamburgers, potato salad, and homemade ice cream sundaes. Within an hour after the meal, several children and parents begin to have nausea, vomiting and stomach cramps. None of those affected have fever. What is the most likely etiologic agent?

Question 21

Stacy, age 27, states that she has painless, white, slightly raised patches in her mouth. They are probably caused by:

Question 22

Treatment of H.pylori includes which of the following?

Question 23

Janine, age 29, has numerous transient lesions that come and go, and she is diagnosed with urticaria. What do you order?

Question 24

A patient comes in complaining of 1 week of pain in the posterior neck with difficulty turning the head to the right. What additional history is needed?

Question 25

Your patient Jerry has gout. What do you suggest?

Question 26

A 70 year old patient presents with a slightly raised, scaly, erythematous patch on her forehead. She admits to having been a “sun worshiper.” The nurse practitioner suspects actinic keratosis. This lesion is a precursor to:

Question 27

Martha had a less than 7% value on her Schilling test. What medication do you anticipate she might need?

Question 28

The nurse practitioner observes a tympanic membrane that is opaque, has decreased mobility, and is without bulging or inflammation. The least likely diagnosis for this patient is:

Question 29

Which statement below is correct about pertussis?

Question 30

An AST that is more than twice the level of ALT is suggestive of:

Question 31

Your 31-year-old patient, whose varicella rash just erupted yesterday, asks you when she can go back to work. What do you tell her?

Question 32

Acute rheumatic fever is an inflammatory disease which can follow infection with:

NRS 434 Compare The Physical Assessments Among School-Aged Children

The needs of the pediatric patient differ depending on age, as do the stages of development and the expected assessment findings for each stage. In a 500-750-word paper, examine the needs of a school-aged child between the ages of 5 and 12 years old and discuss the following:

Compare the physical assessments among school-aged children. Describe how you would modify assessment techniques to match the age and developmental stage of the child.
Choose a child between the ages of 5 and 12 years old. Identify the age of the child and describe the typical developmental stages of children that age.
Applying developmental theory based on Erickson, Piaget, or Kohlberg, explain how you would developmentally assess the child. Include how you would offer explanations during the assessment, strategies you would use to gain cooperation, and potential findings from the assessment.

You are required to cite a minimum of three peer-reviewed sources to complete this assignment. Sources must be published within the last 5 years, appropriate for the assignment criteria, and relevant to nursing practice.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Attachments

NRS-434VN-R-CLC-Agreement-Student.docx
Developmental Assessment and the School-Aged Child – Rubric
Collapse All Developmental Assessment And The School-Aged Child – RubricCollapse All
Comparison of Physical Assessment Among School-Aged Children

27.5 points

Criteria Description

Comparison of Physical Assessment Among School-Aged Children

5. 5: Excellent

27.5 points

A detailed comparison of physical assessments among different school-aged children is presented. How assessment techniques would be modified depending on the age and developmental stage of the child is thoroughly described. Insight is demonstrated into the physical assessment of school age children.

4. 4: Good

24.48 points

A comparison of physical assessments among different school-aged children is presented. How assessment techniques would be modified depending on the age and developmental stage of the child is described. Some information is needed for clarity.

3. 3: Satisfactory

21.73 points

A general comparison of physical assessments among different school-aged children is summarized. How assessment techniques would be modified depending on the age and developmental stage of the child is generally described. More information or support is needed for clarity or accuracy.

2. 2: Less Than Satisfactory

20.63 points

An incomplete comparison of physical assessments among different school-aged children is summarized. How assessment techniques would be modified depending on the age and developmental stage of the child is omitted or contains significant inaccuracies.

1. 1: Unsatisfactory

0 points

A comparison of physical assessments among different school-aged children is omitted.

Typical Assessment for a Child of a Specific Age

27.5 points

Criteria Description

Typical Assessment for a Child of a Specific Age

5. 5: Excellent

27.5 points

The typical developmental stage of a child between the ages 5 and 12 is accurately and thoroughly described.

4. 4: Good

24.48 points

The typical developmental stage of a child between the ages 5 and 12 is described. The overall description is accurate. Some information is needed for clarity.

3. 3: Satisfactory

21.73 points

The typical developmental stage of a child between the ages 5 and 12 is generally described. The description contains some inaccuracies for the age of the child.

2. 2: Less Than Satisfactory

20.63 points

The typical developmental stage of a child between the ages 5 and 12 is summarized. The summary contains significant inaccuracies for the age of the child.

1. 1: Unsatisfactory

0 points

The typical developmental stage of a child between the ages 5 and 12 is not described.

Developmental Assessment of a Child Using a Developmental Theory (Erickson, Piaget, Kohlberg)

33 points

Criteria Description

Developmental Assessment of a Child Using a Developmental Theory (Erickson, Piaget, Kohlberg)

5. 5: Excellent

33 points

A child assessment based on a developmental theory is thoroughly described. Well-developed strategies to gain cooperation and for how explanations would be offered during the assessment are presented. The potential findings expected from the assessment are all accurate and described in detail.

4. 4: Good

29.37 points

A child assessment based on a developmental theory is described. Appropriate strategies to gain cooperation and for how explanations would be offered during the assessment are presented. The potential findings expected from the assessment are described. Some information is needed for clarity.

3. 3: Satisfactory

26.07 points

A child assessment based on a developmental theory is generally described. General strategies to gain cooperation and for how explanations would be offered during the assessment are presented. The potential findings expected from the assessment are summarized. There are minor inaccuracies.

2. 2: Less Than Satisfactory

24.75 points

A child assessment based on a developmental theory is partially summarized. Partial strategies to gain cooperation and for how explanations would be offered during the assessment are presented. The potential findings expected from the assessment are omitted or are incorrect. There are significant inaccuracies.

1. 1: Unsatisfactory

0 points

A child assessment based on a developmental theory is omitted.

Thesis Development and Purpose

5.5 points

Criteria Description

Thesis Development and Purpose

5. 5: Excellent

5.5 points

Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

4. 4: Good

4.9 points

Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.

3. 3: Satisfactory

4.35 points

Thesis is apparent and appropriate to purpose.

2. 2: Less Than Satisfactory

4.13 points

Thesis is insufficiently developed or vague. Purpose is not clear.

1. 1: Unsatisfactory

0 points

Paper lacks any discernible overall purpose or organizing claim.

Argument Logic and Construction

5.5 points

Criteria Description

Argument Logic and Construction

5. 5: Excellent

5.5 points

Clear and convincing argument that presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

4. 4: Good

4.9 points

Argument shows logical progressions. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.

3. 3: Satisfactory

4.35 points

Argument is orderly but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.

2. 2: Less Than Satisfactory

4.13 points

Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.

1. 1: Unsatisfactory

0 points

Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.

Mechanics of Writing (includes spelling, punctuation, grammar, language use)

5.5 points

Criteria Description

Mechanics of Writing (includes spelling, punctuation, grammar, language use)

5. 5: Excellent

5.5 points

Writer is clearly in command of standard, written, academic English.

4. 4: Good

4.9 points

Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.

3. 3: Satisfactory

4.35 points

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.

2. 2: Less Than Satisfactory

4.13 points

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, or word choice are present.

1. 1: Unsatisfactory

0 points

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.

Paper Format (use of appropriate style for the major and assignment)

2.2 points

Criteria Description

Paper Format (use of appropriate style for the major and assignment)

5. 5: Excellent

2.2 points

All format elements are correct.

4. 4: Good

1.96 points

Template is fully used; There are virtually no errors in formatting style.

3. 3: Satisfactory

1.74 points

Template is used, and formatting is correct, although some minor errors may be present.

2. 2: Less Than Satisfactory

1.65 points

Template is used, but some elements are missing or mistaken; lack of control with formatting is apparent.

1. 1: Unsatisfactory

0 points

Template is not used appropriately, or documentation format is rarely followed correctly.

Documentation of Sources

3.3 points

Criteria Description

Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)

5. 5: Excellent

3.3 points

Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

4. 4: Good

2.94 points

Sources are documented, as appropriate to assignment and style, and format is mostly correct.

3. 3: Satisfactory

2.61 points

Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.

2. 2: Less Than Satisfactory

2.47 points

Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.

1. 1: Unsatisfactory

0 points

Sources are not documented.

Total 110 points

Social Impact of Population Growth

Social Impact of Population Growth

The United Nations has hired you to be a consultant on global issues. One of the challenges is assessing the impact of population growth. There is no question that the world population will grow dramatically in the next decade throughout many countries of the world. The members of the UN are working to understand the impact that population growth has on society, specifically in developing countries. Your first project with the UN is to develop a whitepaper on three issues related to the population growth faced by one of these countries. Read the Case Analysis and provide an assessment based on the questions below.

(The instructions for completing this assignment can be found by clicking on “Assignment Attachment .doc file)

++++++++++++++++++++++++++++++++++++++++++++++++++

Review the whitepaper and start your research. If you have any questions about the assignment or the  see the attached PDF document.

Note: Your submission paper to be used and will be checked by the SafeAssign.

.doc file contains the question interaction and

.pdf file contains Strayer Writing Standard.

The United Nations has hired you to be a consultant on global issues. One of the challenges is assessing the impact of population growth. There is no question that the world population will grow dramatically in the next decade throughout many countries of the world. The members of the UN are working to understand the impact that population growth has on society, specifically in developing countries. Your first project with the UN is to develop a whitepaper on three issues related to the population growth faced by one of these countries. Read the Case Analysis and provide an assessment based on the questions below.

(The instructions for completing this assignment can be found by clicking on “Assignment Attachment .doc file)

++++++++++++++++++++++++++++++++++++++++++++++++++

Review the whitepaper and start your research. If you have any questions about the assignment or the  see the attached PDF document.

Note: Your submission paper to be used and will be checked by the SafeAssign.

.doc file contains the question interaction and

.pdf file contains Strayer Writing Standard.

NRS 440 Outline a Current or Emerging Health Care Law or Federal Regulation Introduced to Reform or Restructure Some Aspect of the Health Care Delivery System

Examine changes introduced to reform or restructure the U.S. health care delivery system. In a 1,000-1,250 word paper, discuss action taken for reform and restructuring and the role of the nurse within this changing environment.

Include the following:

Outline a current or emerging health care law or federal regulation introduced to reform or restructure some aspect of the health care delivery system. Describe the effect of this on nursing practice and the nurse’s role and responsibility.
Discuss how quality measures and pay for performance affect patient outcomes. Explain how these affect nursing practice and describe the expectations and responsibilities of the nursing role in these situations.
Discuss professional nursing leadership and management roles that have arisen and how they are important in responding to emerging trends and in the promotion of patient safety and quality care in diverse health care settings.
Research emerging trends. Predict two ways in which the practice of nursing and nursing roles will grow or transform within the next five years to respond to upcoming trends or predicted issues in health care.

You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the last 5 years, appropriate for the assignment criteria, and relevant to nursing practice.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Health Care Delivery Models and Nursing Practice – Rubric

Criteria Description

Current or Emerging Health Care Law or Federal Regulation and Effect on Nursing Practice, Role and Responsibility

5. Excellent

33 points

Discussion on emerging health care law or federal regulation, and effect on nursing practice and the nurse role, and responsibility is well-developed.

4. Good

29.37 points

Emerging health care law or federal regulation, and effect on nursing practice and the nurse role, and responsibility is described. Some information or detail is needed for clarity.

3. Satisfactory

26.07 points

Emerging health care law or federal regulation, and effect on nursing practice and the nurse role, and responsibility is summarized. There are some inaccuracies.

2. Less Than Satisfactory

24.75 points

Emerging health care law or federal regulation is incomplete. Effect on nursing practice and nurse role and responsibility is partially described.

1. Unsatisfactory

0 points

Emerging health care law or federal regulation is omitted. The law or regulation presented is not relevant to health care.

Criteria Description

Quality Measures Pay for Performance, Patient Outcomes, and Effect on Nursing Practice

5. Excellent

33 points

A thorough and insightful discussion on how quality measures and pay for performance affect patient outcomes, and how they affect nursing practice, expectations, and responsibilities of the nursing role, is presented.

4. Good

29.37 points

Discussion on how quality measures and pay for performance affect patient outcomes, and how they affect nursing practice, expectations, and responsibilities of the nursing role, is presented. Some information is needed for clarity.

3. Satisfactory

26.07 points

Summary on how quality measures and pay for performance affect patient outcomes, and how they affect nursing practice, expectations, and responsibilities of the nursing role, is presented. There are inaccuracies or slight omissions.

2. Less Than Satisfactory

24.75 points

Discussion on how quality measures and pay for performance affect patient outcomes, and how they affect nursing practice, expectations, and responsibilities of the nursing role, is incomplete.

1. Unsatisfactory

0 points

Discussion on how quality measures and pay for performance affect patient outcomes, and how they affect nursing practice, expectations, and responsibilities of the nursing role, is omitted.

Criteria Description

Professional Nursing Leadership and Management Roles

5. Excellent

33 points

A well-developed discussion on professional nursing leadership and management roles, and the imporantance of these roles in responding to emerging trends and patient safety and quality care, is presented. The discussion demonstrates a thorough understanding of the nursing profession in emerging trends and patient care in a diverse health setting.

4. Good

29.37 points

A discussion on professional nursing leadership and management roles, and the imporantance of these roles in responding to emerging trends and patient safety and quality care, is presented. Some detail or information is needed for clarity.

3. Satisfactory

26.07 points

A summary on professional nursing leadership and management roles, and the imporantance of these roles in responding to emerging trends and patient safety and quality care, is presented. There are inaccuracies or slight omissions.

2. Less Than Satisfactory

24.75 points

An incomplete discussion on professional nursing leadership and management roles and the imporantance of these roles in responding to emerging trends and patient safety and quality care is presented.

1. Unsatisfactory

0 points

Discussion on professional nursing leadership and management roles and the imporantance of these roles in responding to emerging trends and patient safety and quality care is omitted.

Criteria Description

Predict Change in Nursing Roles and Nursing Practice

5. Excellent

33 points

Predictions for how the practice of nursing and nursing roles will grow or transform within the next 5 years to respond to upcoming trends or predicted issues in health care are thoroughly discussed. The predictions are based on evidence and highly relevant to emerging trends.

4. Good

29.37 points

Predictions for how the practice of nursing and nursing roles will grow or transform within the next 5 years to respond to upcoming trends or predicted issues in health care are discussed. The predictions are generally supported and realistic.

3. Satisfactory

26.07 points

Insert Satisfactory CoA summary on professional nursing leadership and management roles, and the imporantance of these roles in responding to emerging trends and patient safety and quality care, is presented. There are inaccuracies or slight omissions.Predictions for how the practice of nursing and nursing roles will grow or transform within the next 5 years to respond to upcoming trends or predicted issues in health care are summarized. The predictions are realistic, but there are inaccuracies or slight omissions. ntent 2 Descriptor

2. Less Than Satisfactory

24.75 points

Predictions for how the practice of nursing and nursing roles will grow or transform within the next 5 years to respond to upcoming trends or predicted issues in health care are incomplete. The predictions are unrealistic or lack evidence for support.

1. Unsatisfactory

0 points

Predictions for how the practice of nursing and nursing roles will grow or transform within the next 5 years to respond to upcoming trends or predicted issues in health care are omitted.

Criteria Description

Thesis Development and Purpose

5. Excellent

8.25 points

Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

4. Good

7.34 points

Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.

3. Satisfactory

6.52 points

Thesis is apparent and appropriate to purpose.

2. Less Than Satisfactory

6.19 points

Thesis is insufficiently developed or vague. Purpose is not clear.

1. Unsatisfactory

0 points

Paper lacks any discernible overall purpose or organizing claim.

Criteria Description

Argument Logic and Construction

5. Excellent

8.25 points

Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

4. Good

7.34 points

Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.

3. Satisfactory

6.52 points

Argument is orderly but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.

2. Less Than Satisfactory

6.19 points

Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.

1. Unsatisfactory

0 points

Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.

Criteria Description

Mechanics of Writing (includes spelling, punctuation, grammar, language use)

5. Excellent

8.25 points

Writer is clearly in command of standard, written, academic English.

4. Good

7.34 points

Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.

3. Satisfactory

6.52 points

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.

2. Less Than Satisfactory

6.19 points

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, or word choice are present.

1. Unsatisfactory

0 points

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.

Criteria Description

Paper Format (use of appropriate style for the major and assignment)

5. Excellent

3.3 points

All format elements are correct.

4. Good

2.94 points

Template is fully used; There are virtually no errors in formatting style.

3. Satisfactory

2.61 points

Appropriate template is used. Formatting is correct, although some minor errors may be present.

2. Less Than Satisfactory

2.47 points

Template is used, but some elements are missing or mistaken; lack of control with formatting is apparent.

1. Unsatisfactory

0 points

Template is not used appropriately, or documentation format is rarely followed correctly.

Criteria Description

Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)

5. Excellent

4.95 points

Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

4. Good

4.41 points

Sources are documented, as appropriate to assignment and style, and format is mostly correct.

3. Satisfactory

3.91 points

Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.

2. Less Than Satisfactory

3.71 points

Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.

1. Unsatisfactory

0 points

Sources are not documented.

Total 165 points

NURS 601B APRN Bridge course

Week 7 Assignment  

Comprehensive H&P Case Study

The purpose of this paper is to understand the importance of accurate medical record documentation to record pertinent facts, findings, and observations about a patient’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.

Directions:

Step 1:

Review and critique the comprehensive H&P and thoroughly answer the questions that follow in complete sentences and paragraphs using question and answer APA format.

Step 2:

Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.

Step 3:

Keep in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by CMS. Visit  CMS.gov, and then search “1997 Guidelines of Documentation for Evaluation and Management” for information that should be included in a medical record.

Answer the following questions:

1. Does this document meet the CMS guidelines for documentation of a comprehensive history and physical? Why or why not? Be specific.

2. Critically analyze the H&P and list any errors. Identify the strengths of the H&P.

3. Did any questions come to mind that you are unable to answer after reading the H&P?

4. Are the conditions listed in the assessment section reasonably supported by the history? Why or why not? Explain your rationale.

5. Did you identify other differential diagnoses or conditions that should be included in the assessment? If so, list them.

6. List the ICD-10 code for each of the following (go to  CMS.gov and search for the ICD-10 Codes):

Moderate persistent asthma with (acute) exacerbation: ______________

Pneumonia, unspecified organism:  ______________

Essential (primary) hypertension: ______________

Hyperlipidemia, unspecified ______________

Obesity: ______________

7. Is it appropriate to include the ICD-10 code for pneumonia when billing for this visit? Why or why not?

8. Is the plan reasonable based on the assessments listed? Why or why not?

9. List 3 patient education strategies relevant to the case study including specific medication teaching. Include references.

10. List health promotion recommendations from AHRQ according to age/gender/conditions. Cite your references.

Your paper should be 2-3 pages not including the title and reference pages. A minimum of 2 sources, not including your texts, must be incorporated into your paper.

Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.

601B Comprehensive H&P guidelines.docx

A comprehensive H&P for patient Anne Smith is shown. Ms. Smith is a new patient presenting to an internal medicine office-based practice. Carly Sanders, an experienced nurse practitioner, authored the H&P.

Patient Name: Anne Smith                                      Age: 55

Date of Visit:    2-14-2016                                       Gender: Female

Information Source: Patient, reliable source, face-to-face office visit

Subjective:

Chief Complaint: Follow up after Emergency Department visit

History of Present Illness: Reports were seen in the Emergency Department approximately 2 weeks ago and was treated for bronchitis with an unknown antibiotic that she has now finished. Was prescribed a refill of an Albuterol MDI as well. Pt continues to report cough and shortness of breath with exertion. Cough and shortness of breath have not improved since last Emergency Room visit. Cough reported as dry and present day and night without provocation. Has been using Albuterol MDI 4–5 times per day with slight relief of shortness of breath symptoms. Pt reports multiple diagnoses of bronchitis last year and has been using Albuterol MDI multiple times daily for the past 6 months or more.

PMH: Hypertension. Bronchitis. Hyperlipidemia. Obesity.

Medications: HTCZ 25mg BID. Albuterol MDI q4h PRN. Simvastatin 20mg daily. OTC Aleve 1–2 tabs PRN headaches.

Allergies: Codeine. Shellfish.

Family History: Mother and Father with CV disease. Son with asthma. Daughter with hypertension. Denies family history of DM. Mother diagnosed with breast cancer at age 40, died at 44.

Social History: Retired from clerical work. Widowed. Lives with adult children and assists with watching grandchildren. Denies tobacco use, ETOH use, drug use.

Review of Systems:

GENERAL: Reports good sleep but decreased energy levels. Denies fever.

CV: (-) palpitations. (-) CP. (-) swelling.

PULM: (+) SOB with exertion. (+) wheezing. (+) dry cough. (-) hemoptysis.

ENT: (-) rhinorrhea. (-) sinus pain/pressure. (-) ear pain/pressure. (-) sore throat.

Objective:

CV: RRR, no murmur.

Pulm : Posterior inspiratory wheezes bilaterally in all lobes. No rales/rhonchi/crackles. No consolidation present with percussion. Equal rise and fall of chest. No accessory muscle use.

Ears: Bilat TM pearly white, canals clear, no discharge, no external ear tenderness.

Nose: Nasal mucosa pink, moist. No discharge present. No sinus pressure pain.

Throat/Neck: Oral mucosa pink/moist. Tonsils grade 1 without exudate. No lymphadenopathy.

General: Obese caucasian female. Affect appropriate. Appears very anxious. Appropriately dressed. No obvious deformity.

VS: Temp 97.8, Pulse 72 RR 22, BP 140/90, BMI 32

Assessment:

1. Moderate persistent asthma with (acute) exacerbation

2. Pneumonia, unspecified organism

3. Essential (primary) hypertension

4. Hyperlipidemia, unspecified

5. Obesity

Plan:

Dx Plan: None

Tx Plan: Rx: Qvar 40mcg/spray 2 puffs BID. Rx: Albuterol MDI 1-2puffs q4h PRN wheezing. Rx: Inhalation Spacer Device. Refill HTCZ 25mg PO BID #30 with 2 refills.

Refill Simvastatin 20mg PO QD #30 with 2 refills.