Benchmark Academic Clinical History And Physical Note

Question

Benchmark Academic Clinical History And Physical Noteacademic Clinic Benchmark - Academic Clinical History and Physical Note Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating evidence-based plans of care. Complete an academic clinical history and physical note based on a patient seen during clinical. In your assessment, provide the following. ( Acute Care Hospital) History and Physical Note 1. Chief complaint/reason for admission/visit/consult. 2. HPI for the H&P or consult notes. 3. Medical, surgical, family, social, and allergy history. 4. Home medications, including dosages, route, frequency, and current medications, if a consultation note 5. Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system). 6. Vital signs and weight. 7. Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam. 8. Lab/Imaging/Diagnostic test results (including date). (CPT codes) Assessment and Clinical Impressions 1. Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale. (ICD-10 codes) 2. Include a complete list of all diagnoses that are both acute and chronic. 3. List the differential diagnoses and chronic conditions in order of priority. Plan Component Management and Plan Criteria Incorporation 1. Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale. 2. Discuss disposition and expected outcomes. 3. Identify and address health education, health promotion, and disease prevention. 4. Provide case summary with ethical, le

Dr. Jack HW Helper · Accepted Answer

Introduction The process of developing a comprehensive clinical history and physical examination report is vital in acute care settings, particularly for nurse practitioners tasked with diagnosing and managing complex conditions. This paper presents a detailed assessment designed around a hypothetical patient encounter, following the structured guidelines provided for compiling such notes. The focus is on demonstrating advanced clinical reasoning, evidence-based decision-making, and holistic patient care during the process. Chief Complaint and Reason for Visit The patient, a 68-year-old male with a history of hypertension and type 2 diabetes mellitus, presents with a sudden onset of chest pain radiating to the left arm, accompanied by shortness of breath and diaphoresis. He reports that the pain started two hours prior to presentation and has been persistent. The reason for the consult is to evaluate for potential acute coronary syndrome (ACS). History of Present Illness (HPI) The patient describes the chest pain as a pressure-like sensation, 8/10 in intensity, non-radiating initially but now radiates to the left arm and neck. It worsened with exertion but has persisted at rest. He reports associated nausea, sweating, and dizziness. The pain duration is approximately two hours. No recent trauma, fever, or cough. He has a history of regular hypertension management but admits non-compliance with medication. He denies prior episodes of similar chest pain. Medical, Surgical, Family, Social, and Allergy History Medical history includes hypertension, type 2 diabetes mellitus, and hyperlipidemia. Surgical history is notable for an appendectomy at age 20. Family history reveals a father with myocardial infarction at age 70 and a mother with stroke at age 75. The patient is a former smoker (20 pack-years, quit 10 years ago). Socially, he consumes alcohol socially and reports limited physical activity due to sedentary work. He has no known drug allergies but is allergic to pe

Benchmark Academic Clinical History And Physical Note

Benchmark Academic Clinical History And Physical Noteacademic Clinic

Paper For Above instruction

Introduction

Chief Complaint and Reason for Visit

History of Present Illness (HPI)

Medical, Surgical, Family, Social, and Allergy History

Home Medications

Review of Systems

Vital Signs and Weight

Physical Examination

Laboratory and Diagnostic Test Results

Assessment and Clinical Impressions

Plan and Management

Conclusion

References