history. This will include a complete head-to-toe review of systems (ROS) and a complete head-to-toe physical examination. This will be documented in a SOAP note format.
The patient should be an adult over the age of 18 with a chief complaint. Please do not choose the same friend or family member from previous course assignments.
Document a working diagnosis and a minimum of 3 differential diagnoses. These are based on the chief complaint (CC) an history of present illness (HPI). All 3 diagnoses Working diagnosis and differential diagnoses must include pertinent positive and negative symptoms. You may also include known diagnoses, such as obesity or hypertension. These do not need pertinent findings.
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Assignment Details
*The Subjective health history and Objective physical exam must contain all required elements as outlined in Jarvis Chapter 27 (except breast and genital exams) and the attached document. The Assessment, as well as the Plan, will be focused based on CC and HPI.
*Read the rubric for the Comprehensive Health Assessment assignment carefully.
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*The assignment submission should be a single document that contains:
1.A complete subjective history
2.A complete objective examination
3.Working diagnosis with at least 3 differential diagnoses with pertinent findings for each
4.Plan of care that includes a discussion of the national guidelines for your diagnosis and health maintenance needs for your patient
**I have attached flies for this papers**
MODEL ANSWER
Subjective Data
Biographic Data
The patent is a 62-year-old female African | PLACE YOUR ORDER NOW AT writtask.com | mother who stays with her 28-year-old daughter. She speaks English although | PLACE YOUR ORDER NOW AT writtask.com | never formally employed, she used to work as a community health volunteer.
Source:
Chief Complaint: Patient complains of experiencing pain on several finger joints over her | PLACE YOUR ORDER NOW AT writtask.com | has gotten worse such that she can no longer work effectively in her small garden.
History of Present Illness (HPI): The pain started around a month ago with the location being the bilateral finger joints. The pain has been persistent with the | PLACE YOUR ORDER NOW AT writtask.com | doing small tasks and relatively low when free. The aggravating factor for the pain is tasks done in the garden. As for the relieving factor, patient doesn’t take any medications presently as the pain isn’t very sharp when free. However, the patient used painkillers twice at the first few days after the | PLACE YOUR ORDER NOW AT writtask.com | is that the patient is no longer able to work in her garden due to the pain (Venables & BChir, 2019).
Past Medical History:
Childhood illness: The patient doesn’t have any notable childhood illness
Surgical History: None
Hospitalizations: was hospitalized for | PLACE YOUR ORDER NOW AT writtask.com | at the age of 3 and experience an accident which was not severe at the age of 40
Transfusions: No history of blood transfusion
Psychiatric history: No history of mental illness
Family History:
Father: Both father and mother passed on at the age of 86 and | PLACE YOUR ORDER NOW AT writtask.com | diagnosed with stomach cancer while the mother died of hypertension. Both had obesity complications. They however didn’t report any blood | PLACE YOUR ORDER NOW AT writtask.com | was the only sibling but has a step brother who is 57 with obesity-related complications.
Allergies: No drug allergies
Review of Systems using Objective data
General Appearance: The patient doesn’t have a history of fever, chills and | PLACE YOUR ORDER NOW AT writtask.com | reports weight loss and seem to get tired easily. Cannot be able to keep up with the garden work and hence relies on the daughter for all garden chores.
The level of consciousness is normal and appears healthy
Nutritional status: no nutritional complication.
The skin color: black.
Posture: Patient is stable | PLACE YOUR ORDER NOW AT writtask.com | walks with no support. No physical deformities
Mobility: No assistive device and no | PLACE YOUR ORDER NOW AT writtask.com | movement reported. Also, able to rise from a seated position
Facial Expression and mood: Appear happy and settled with no anxieties.
Speech: Talks in stable tone | PLACE YOUR ORDER NOW AT writtask.com | a proper expression of emotions. The content is also appropriate.
Hearing: Can only hear when the person talking is close by.
Measurement
Weight: The patient weighs | PLACE YOUR ORDER NOW AT writtask.com | kg (170.9 lb)
Height: 5 ft 4 inches tall
Wait circumference: 38.6 inches
BMI = weight/height2 = 77.5/1.632 = 29.18kg/m2
Vision: Snellen eye chart gives 20/40 | PLACE YOUR ORDER NOW AT writtask.com | as the patient can only see what is very close to them.
Skin
The skin appears pale and dehydrated. However, the skin color appears normal
Vital Signs
Radial pulse: The pulse is symmetrical, | PLACE YOUR ORDER NOW AT writtask.com | and within the normal rate (80 per minute)
Respirations: normal respiration with 16 breaths taken per minute
Blood pressure in arms and legs: the blood | PLACE YOUR ORDER NOW AT writtask.com | s 130/80 and the patient could be developing blood pressure
Temperature: Not indicated
Head and Face
Scalp, hair and cranium: Hair has a rough texture with | PLACE YOUR ORDER NOW AT writtask.com | pattern showing no hair loss, cranium is tender and symmetrical head
Face: Face is symmetrical
Maxillary and frontal sinuses are normal
Eyes
External ocular structures show: facial | PLACE YOUR ORDER NOW AT writtask.com | is relaxed and not tense; eyebrow movement is symmetrical. Eyelids and lashes show that there is no swelling, redness or lesions.
The eyelid is closed completely and not drooping
Conjunctivae show that the eyeball is | PLACE YOUR ORDER NOW AT writtask.com | and sclera is white with notable gray-blue hue
The pupil size is 3mm in diameter during | PLACE YOUR ORDER NOW AT writtask.com | and 4mm in the dark. However, patient can only visualize objects that are in close range.
The ophthalmoscope | PLACE YOUR ORDER NOW AT writtask.com | that the ocular fundus: red reflex, disc, vessels and retinal background are all normal. Recently developed vision impairment which is however a historical problem
Ears The otoscopy shows that the ear is | PLACE YOUR ORDER NOW AT writtask.com | yellow and cloudy tympanic. It has an air fluid level behind the | PLACE YOUR ORDER NOW AT writtask.com | discharge in the auditory canal. The ears are also tender with a normal ear skin condition. No pain and discharge from the ears. There is however a notable impairment in hearing due to old age…
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