(Answered) NU610-7A: Advanced Health Assessment

(Answered) NU610-7A: Advanced Health Assessment

(Answered) NU610-7A: Advanced Health Assessment 150 150 Prisc

NU610-7A: Advanced Health Assessment

Chief Complaint: Headache at the left side of the head, continues for two days
History of present illness: Pt is 40 years old female complains of headache, mainly at the left side of the head for two days. Pt states that she has headaches periodically for past two years, usually one or two episodes a month, each episode lasts for 3-4 hours and resolves with using Advil or Excedrin.
Past medical history:. Pt doesn’t have any comorbid diseases, had appendectomy at the age of 24, C-section 6 years ago.
Allergy: Pt has no known drug, food, or environmental allergy.
Medication reconciliation: Pt takes over-the-counter multivitamins every day, Advil or Excedrin (dose unknown) for headaches PRN.
Social history: Pt has college degree and works at the hospital. Married and has three young children. Pt denies drinking alcohol, using tobacco or any illicit drugs.
Family history: Pt’s mother has HNT and hyperlipidemia, father is in good health and doesn’t have any health conditions, two siblings are in very good health. Paternal grandparents had very good health and died in their late 80s, maternal grandmother died at 87 from heart attack, maternal grandfather died at 60 from peritonitis.
Health promotion: Pt has regular physical/wellness visits to her PCP, has well woman exams once in three years, used to go to gym twice a week before pandemic started. Pt eats healthy diet and tries to be more active.

Review of systems:
 General Pt denies fever, chills, weight loss/gain.
 HEENT Pt denies any changes in vision, any lesions or tenderness on the scalp. Pt denies any hearing changes, any sinus pain, gag reflex present. Pt admits headaches on the left side of the head
 Skin Pt denies any skin problems, rash, dryness.
 GI Pt denies abdominal pain, nausea and vomiting.
 GU Pt denies any incontinence or changes in urine frequency.
 CV Pt denies any SOB or chest tightness.
 Lungs Pt denies any SOB, denies cough or difficulty breathing.
 Neuro Pt admits headaches but no numbness or tingling.
 Neck Pt admits stiffness and tenderness in neck.
 PV Pt denies leg cramps or varicose veins, denies skin discoloration or edema.
 MSK Pt denies muscle weakness but admits stiffness tenderness in the neck.
 Endo Pt denies heat/cold intolerance, excessive sweating or increased thirst.
 Psych Pt denies depression, mood changes but admits light anxiety and being stressed.

Objective Data:
 VS BP 90/76, HR 65, RR 17, T 36.6
 General Looks well-nourished and not in distress.
 HEENT Head is symmetrical, no abnormalities noted. PERRLA, EOM intact, conjunctiva and sclera clear. Nasal mucosa is clear, throat is clear. No neck masses.
 Skin. No abnormal rashes or lesions, normal turgor.
 GI Abdomen is flat, soft, normoactive bowel sounds. No tenderness, rebound or masses.
 GU No assessment performed (pt refused).
 CV S1/S2 heard, rate and rhythm are normal, no murmurs, no cyanosis.
 Lungs Lung sound clear and equal in all areas, no adventitious sounds, no abnormalities noted.
 Neuro No abnormalities in sensation, cranial nerves intact, reflexes present. Motor exam normal.
 Neck Neck is symmetrical, no palpable lymph nodes, but tender.
 PV No skin discoloration or any abnormalities noted. Cap refill < 3seconds.
 MSK Neck tenderness but no diminished range of motion, no joint tenderness, no edema, normal gait.
 Psych PHQ-9 assessment is negative.

please contact me if have any questions, remember, don’t need space, I don’t care about typing format, just keep format of assessment, it should go exactly in same order, just little more detailed, if need to fit all of it in three pages do it, again just need info in the order it was given for three patients you choose.

Sample Answer

Case Study One

Chief Complaint: Weakness and Swelling of the Ankles

History of the Present Illness. M.J is a 42-year-old female who visited the clinic with a complaint of swelling of both ankles. The swelling started four weeks ago but was not a concern until she started experiencing weakness. The patient appeared pleasant, with no distress noted. She was diagnosed with hypertension two years ago, and she has been taking her medication, observing the diet, and exercising regularly. She has lost weight, and her blood pressure is under control. She denies any other illness. She also denies smoking, alcohol, and substance abuse.

Past Medical History: She denies any other illness. She reported one caesarian section 8 years ago.

Allergy: M.J denies any food or drug allergy

Medication: She is on Amlodipine prescription 10mg 1-tab PO daily

Social History: She is a college graduate, and she operates her own business with the help of her cousin. She is married and has two children. She lives with the husband and her mother-in-law. She helps in taking care of the mother-in-law who got her leg amputated. She hangs out with a group of friends in the neighborhood twice once a month. She denies abusing alcohol or any drugs.

Family History: Both parents are alive. The mother has hypertension, and she is overweight, although she has been able to keep her blood sugar under control. The father is healthy. M.J reports a family history of type 2 diabetes, obesity, atherosclerosis, and lung cancer. She denies any family history of mental health issues and substance abuse.

Health Promotion:  M.J reports eating healthy, drinking natural juices, eight glasses of water every day, drinks half a cup of coffee every morning, and attends the gym three times a week. She engages in outdoor activities with the family during the weekends. She reports performing self-breast examination twice a month, wears her seat-belt while driving, and sleeps well for a minimum of eight hours every night.

Review of systems:

  • General M.J reports weakness, weight loss, denies fever and chills.
  • HEENT M.J reports vision changes and uses corrective lenses; she denies hearing problems, pain, discharge, or ringing in the ears. she denies throat pain, hoarseness, nose         bleeding, sinus problems, dental issues, and dysphagia
  • Skin M.J denies skin problems, skin discoloration, bruises, delayed healing, rashes, and any changes in lesions.
  • GI M.J reports constipation, denies abdominal pain, nausea, and vomiting.
  • GU M.J denies any changes in urine frequency, vaginal discharge, and STDs.
  • CV MJ denies coughing, wheezing, dyspnea, difficulties in breathing.
  • Lungs denies chest tightness.
  • Neuro M.J reports weakness, denies seizures, blackout spells, syncope, and transient paralysis.
  • PV M.J reports edema, leg cramps. Denies varicose veins.
  • MSK M.J reports ankle swelling and muscle weakness. She denies stiffness and tenderness.
  • Endo M.J denies increased thirst, hunger, cold, or heat intolerance. She denies night sweat, swollen glands, bruising, and blood transfusion.
  • Psych M.J denies anxiety, mood changes, sleeping problems. Reports stress.

Objective Data:

  • VS BP 118/81, HR 86, RR 14, T 36.8, W 150, H 5’5, BMI 25.
  • General Appearance. M.J appears alert, well-groomed, oriented, and maintains eye contact during the conversation. No acute distress was noted.
  • HEENT head appears normocephalic; hair is evenly distributed; the head is atraumatic       with no lesions. PERRLA, EOM intact, no conjunctival and scleral injection. Canal           patents   clear. Easily visible landmarks. Pink and moist nasal mucosa, no septal                   deviation, normal turbinates. The neck feels supple, with no occipital nodes, no nodules.          No tooth decays.
  • Skin. Skin appears white, intact, clean, and warm. No lesions or cyanosis were noted. Pelvic scar noted for the cesarean section.
  • GI abdomen flat, pelvic scar visible, active BS in all four quadrants, no tenderness,      no hepatosplenomegaly. Normoactive bowel sounds.
  • GU bladder is non-distended.
  • CV regular rhythm and rate, no murmurs, clicks, or rubs. Capillary refill occurs in two seconds, pedal edema bilateral, the pulse is 3+ throughout.
  • Lungs chest walls are symmetrical, clear bilateral auscultation, no abnormalities noted.
  • Neuro speech is clear, normal gait, posture is erect, good tone, balance stable.
  • MSK swollen ankles. Full ROM visible in all four extremities with patient movement.
  • Psych clear speech, appropriate answer, appears alert and oriented, maintains eye contact.

Case Study Two

Chief Complaint: Suspects Urinary Tract Infection

History of the Present Illness: C.S is a 32-year-old African American female. She complains of frequent visits to the bathroom for the last three days. Her normal urinary frequency, as she recalls, has always been an average of four times per day. For the last three days, the frequency has increased to eight times, characterized by the inability to produce urine every time. She also reports experiencing a burning sensation while urinating. She made the appointment yesterday after experiencing abdominal pains, which worsens with the urge to urinate. She rates the pain as 7/10. She thinks it is a urinary tract infection since she had experienced similar symptoms years ago and was diagnosed with a UTI.

Past Medical History: she suffered from chickenpox as a child. She suffered a urinary tract infection and migraine as a young adult.

Allergies: reports being allergic to penicillin. No food allergy reported

Medication: she is currently using no medication.

Social History: She is a college graduate working as a cashier at a mall. She has two children. She lost one child when the child was three months. She lives with her husband. She admits to smoking cigarettes occasionally, especially when she gets stressed. She denies abusing alcohol. She enjoys outdoor activities with family and friends. She actively participates in voluntary community projects. She sings in the choir in her church. Her mother is a single mum, and she has no knowledge about her dad.

Family History: Her mother Is asthmatic, has type 2 diabetes, and has hypertension. There is a history of substance abuse in the family. Maternal grandfather died from diabetes complications.  She denies mental health illnesses and cardiovascular diseases in the family.

Health Promotion: They eat out at the mall most of the time and only cook three to four times a week. She has a regular exercise routine. She takes caffeine daily. She monitors her weight periodically. She conducts a self-test for breast cancer after every three months. She reports wearing her self-belt every time she is traveling.

Review of System

General C.S denies fatigue, fever, headache, and malaise

  • HEENT C.S denies blurry vision, eye itching, drainage, pain. She also denies ear pain, loss of hearing, drainage, popping, fullness. She denies nose drainage, sinus pressure,            allergy, and loss of smell. She reports gum pain, difficulties in chewing, and tooth pain.         She denies difficulty swallowing, sore throat, bleeding gums, and loss of taste.
  • Skin C.S denies skin bruising, rashes, acne, itching, new moles, or other skin changes.
  • GI C.S denies constipation, indigestion reflux, diarrhea, melena, nausea, and vomiting. She reports abdominal pains and pressure.
  • GU C.S reports changes in urine frequency. She complains of polyuria, burning, dysuria, incomplete bladder emptying, no hematuria, and increased frequency. She complains of        an offensive urine odor and back pain. LMP was three weeks ago, lasting four days. Her      periods have always been regular.  Describe the flow as normal.
  • CV CS denies coughing, wheezing, dyspnea, sputum production, and difficulties in breathing.
  • Lungs denies chest tightness, chest pain, palpitations, syncope, or shortness of breath