Adult Health History and Examination ND Health Assessment and Screening NRS 434-V Health History and Examination LH Client/Patient Initials: LH Sex: F Age: 47 Occupation: Registered Nurse Health History/Review of Systems Neurological System headaches‚ head injuries‚ dizziness‚ convulsions‚ tremors‚ weakness‚ numbness‚ tingling‚ difficulty speaking‚ and difficulty swallowing etc.‚ medication): Neurologically JP is intact. Alert ox3 clear speech with no hesitations‚ c/o headaches and dizziness
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Health History and Examination Health Assessment of the Head‚ Neck‚ Eyes‚ Ears‚ Nose‚ Mouth‚ Throat‚ Neurological System‚ and the 12 Cranial Nerves Skin‚ Hair‚ Nails‚ Breasts‚ Peripheral Vascular System‚ Lymphatics‚ Thorax‚ Heart‚ Lungs‚ Musculoskeletal‚ Gastrointestinal‚ and Genitourinary Systems Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include relevant data for your client. Student Name: Date: Client/Patient Initials:
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HISTORY AND PHYSICAL EXAMINATION Patient Name: Deanna Martinez ID No.: 117232 Room No.: 425 Date of Admission: 05/26/2013 Admitting Physician: Sheila Goodman‚ MD Admitting Diagnosis: Questionable herniated disk Chief Complain: Low back pain‚ right leg pain. HISTORY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain. She said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent
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[pic] HISTORY AND PHYSICAL EXAMINATION (H&P) Patient Name: Brenda Seggerman Hospital No.: N/A Room No.: N/A Date of Admission: 03/27/- - - - Admitting Physician: Alex Mcclure‚ MD Admitting Diagnosis: Ectopic Pregnancy HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. The patient denies the chance of pregnancy‚ although the patient states that she
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HILLCREST MEDICAL CENTER HISTORY AND PHYSICAL EXAMINATION Patient Name: Emma Parker Hospital No.: 11259 Room No.: 444 Date of Admission: 09/25/2010 Admitting Physician: Sherman Loyd‚ M.D. Admitting Diagnosis: Acute intertrochanteric fracture of right hip. The history below was obtained from the patient and physical examination was performed with her stated verbal understanding and consent. She was alert oriented x3 with reasonable thought content she understood questions
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Admission: 06/22/…. Admitting Physician: Leon Medina‚ MD Internal Medicine Admitting Diagnosis: Stomatitis possibly methotrexate related. Chief Complaint: Swelling of lips causing difficulty swallowing. HISTORY OF PRESENT ILLNESS: This patient is a 57-year-old Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago she developed a respiratory infection for which she received antibiotics
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ANALYZING A FAMILY HEALTH ASSESSMENT Analyzing a Family Health Assessment Frizzle D Jackson Grand Canyon University: NRS 429 V June 26‚ 2010 Analyzing a Family Health Assessment A family health assessment is a process by which a nurse evaluates and describes the health status of a given family. It is a framework that helps to identify areas of potential risk for illness‚ opportunities for health education and actions needed to address these (World Health Organization‚ 2001)
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Individual Client Health History and Examination Grading Criteria | Possible Points | Points Earned | Instructor’s Comments | Health History/Review of Systems: *Information is complete. *Information is appropriate‚ demonstrating understanding of the specified information. * No errors in spelling or grammar. |
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Family Health Assessment Prabha Andrews Grand Canyon University Family Centered Health Promotion NRS-429V-O103 Shauna Wise April 6‚ 2014 Introduction Family is considered the natural and fundamental unit of the society. The family members make up the family as a structure. Family includes members of different age group
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History and Examination of the Reproductive System Female reproductive history: - Age‚ gravidity (no. of pregnancies‚ including miscarriages/ectopics/stillbirths)‚ parity (no. of livebirths)‚ LMP (last menstrual period) - History of presenting complaints: o Nature and duration o Relation to menstrual cycle o Vaginal discharge o Vaginal bleeding o Urinary symptoms (dysuria‚ frequency‚ urge/stress incontinence) o Bowel symptoms - Previous gynaecological history: o Periods – regular
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