Complete The Health Assessment Check-Off Project Template ✓ Solved
Complete The Health Assessment Check Off Project Template Using A Pa
Complete the "Health Assessment Check-Off Project" template using a patient that you have previously worked with. Ensure that you have adequately completed the assessment steps and given a proper recommendation. APA style is not required, but solid academic writing is expected. 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 not required to submit this assignment to LopesWrite. Health Assessment Check-Off Project Physical Exam Documentation Chief Complaint: History of Present Illness: Past Medical History (Hx): Past Surgical Hx: Family Hx: Social Hx: Allergies: Medications: Review of symptoms by system: Physical Exam: Assessment: Treatment Plan:
Sample Paper For Above instruction
Introduction
The health assessment process is a comprehensive approach utilized by health care professionals to evaluate a patient’s overall health status, identify health risks, and develop an appropriate management plan. This paper demonstrates a detailed health assessment of a hypothetical patient, integrating vital information and clinical findings, and culminating in a tailored treatment plan. Such assessments are vital in primary care settings to facilitate early diagnosis and promote optimal health outcomes.
Chief Complaint
The patient, a 45-year-old female, presents with intermittent chest pain over the past two weeks. She describes the pain as a tight, squeezing sensation located substernally, occasionally radiating to her left arm. The pain is exacerbated by physical exertion and relieved with rest. She reports associated symptoms of shortness of breath and mild fatigue but denies dizziness, nausea, or syncope.
History of Present Illness (HPI)
The patient reports that the chest discomfort started approximately two weeks ago, initially occurring after strenuous activities. The episodes have increased in frequency from once a week to daily occurrences, lasting about 10-15 minutes each. She notes that the pain intensity is moderate and occasionally associated with sweating. The symptoms worsen with physical activity and improve with rest. No recent trauma or hospitalization. She has tried over-the-counter antacids without relief. The patient is concerned about the possibility of cardiac issues.
Past Medical History (Hx)
The patient has a history of hypertension diagnosed five years ago, managed with lifestyle modifications and antihypertensive medication. She has also been treated for hyperlipidemia for three years. No history of diabetes mellitus, respiratory illnesses, or previous cardiovascular events. No known drug allergies or adverse reactions.
Past Surgical Hx
She underwent appendectomy at age 20 and had no prior surgeries related to the cardiovascular system.
Family Hx
Her father had a myocardial infarction at age 52, and her mother has a history of hypertension and hyperlipidemia. No known history of inherited cardiac disorders.
Social Hx
The patient is a non-smoker and consumes alcohol socially on weekends. She works as a school teacher and leads a sedentary lifestyle. She reports a balanced diet but admits to high stress levels due to work. She denies illicit drug use.
Allergies
No known drug or environmental allergies.
Medications
Lisinopril 10 mg daily, atorvastatin 20 mg daily.
Review of Symptoms by System
- General: Occasional dizziness, no weight changes.
- Cardiovascular: Chest pain, shortness of breath on exertion.
- Respiratory: No cough or wheezing.
- Gastrointestinal: No nausea or vomiting.
- Musculoskeletal: No joint pain.
- Neurological: No headaches or neurological deficits.
- Endocrine: No symptoms of thyroid dysfunction.
Physical Exam
- Vital Signs: BP 140/88 mm Hg, HR 82 bpm, RR 16/min, Temp 98.6°F.
- General: Alert, no acute distress.
- Cardiovascular: Regular rhythm, S1 and S2 auscultated normally, no murmurs or gallops. Peripheral pulses palpable and symmetrical.
- Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.
- Abdomen: Soft, non-tender, no hepatosplenomegaly.
- Extremities: No edema, pulses 2+.
- Neurological: Cranial nerves grossly intact, no focal deficits.
Assessment
The patient presents with classic symptoms suggestive of stable angina, likely secondary to atherosclerotic coronary artery disease given her risk factors (hypertension, hyperlipidemia, family history). Further diagnostic testing is necessary to confirm the diagnosis and assess severity.
Treatment Plan
- Diagnostic Tests: Recommend stress electrocardiogram, lipid profile, and echocardiogram.
- Lifestyle Modifications: Encourage smoking cessation if applicable, diet modification to reduce saturated fats, maintain physical activity, and stress reduction techniques.
- Pharmacologic Management: Continue current antihypertensive and lipid-lowering medications; consider adding aspirin 81 mg daily after cardiology consultation.
- Patient Education: Discuss recognition of anginal symptoms, importance of medication adherence, and when to seek emergency care.
- Follow-up: Schedule follow-up in 2 weeks to review diagnostic results and adjust treatment as needed. Consider referral to a cardiologist.
Conclusion
A comprehensive health assessment provides vital insights into a patient's condition, guiding targeted intervention and improved health outcomes. Proper documentation and adherence to clinical guidelines ensure that patient care is optimized and evidence-based.
References
- American College of Cardiology Foundation. (2020). Guidelines for the diagnosis and management of stable ischemic heart disease. Journal of the American College of Cardiology.
- Huq, M. A., & Davis, P. (2018). Hypertension and heart disease: An integrative approach. Cardiology Clinics, 36(4), 561-574.
- Johnson, L. M., & Smith, R. K. (2019). Managing hyperlipidemia in primary care. Journal of Clinical Lipidology, 13(2), 239-245.
- McGill, M. A., & Dewey, F. E. (2021). Family history and cardiovascular risk assessment. Circulation, 143(15), 1489-1491.
- National Institute for Health and Care Excellence. (2016). Chest pain of recent onset: assessment and diagnosis. NICE guidelines.
- Qureshi, A. I., & Khatri, P. (2020). Clinical evaluation of chest pain: A comprehensive review. Annals of Internal Medicine, 172(5), 332-337.
- Rizzo, M., & Giansanti, L. (2017). Lifestyle interventions in cardiovascular disease prevention. Current Cardiology Reports, 19(9), 94.
- American Heart Association. (2018). Guideline for the management of patients with stable angina. Circulation, 138(21), e733–e781.
- Wang, T. J., & Levy, D. (2019). Family history in cardiovascular disease. JAMA Cardiology, 4(10), 1033-1034.
- Yusuf, S., & Hawken, S. (2019). Prevention of cardiovascular disease: The importance of risk factor modification. The Lancet, 394(10216), 658-670.