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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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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The aim of this assignment will be to select a client cared for on a placement and look at the assessment tools used to provide holistic care for this client. It will examine the various assessments used on this client and discuss the holistic needs of the client. My placement area was with a Community Mental Health Team and so the assessment tool used was the Community Mental Health Team Assessment and Progress Record. Carpenito-Moyet (2005‚ p.231) defined an assessment as “the deliberate and
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Emergency Contact #: 7807072266 Relationship to Client: Mother II. HEALTH HISTORY Present health history Client claimed that to be in good health until she then experienced some health problems for about two months now . The health problems are minor as the most studying students have . The client has complained about her irregular sleeping habits . She said that
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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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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
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NSG306 Health Assessment: Health History on Mr. Ricky Ricardo Jean Bors-Koefoed & Sarah Wright Baptist College of Health Sciences Health History Biographical Data Date: 05-23-2010 Name: Ricky Ricardo Gender: Male Race/Ethnicity: Hispanic Marital Status: Married Date of Birth: XX/XX/XX Occupation: Medical Device Representative Address: XXX XXXX XXXXXXXXXXXXXXX Phone Number: (XXX) XXX-XXXX Contact Person (relationship to patient): Lucille
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Introduction Health assessment thus plays an important role to provide information about one’s health. Assessment is the first step in the nursing process and includes collection‚ verification‚ organization‚ interpretation and documentation of data.(Sue C.DeLaune and Patriciak .Ladner‚2011) Almost every admitted patient the first time required the implementation of the health assessment to determine their health condition to enable healthcare plans and implementation what they need to do. On way
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Better Health for Individuals * Identifies and examines why individuals give different meanings to health * Explains how a range of health behaviors affect an individual’s health * Describes how an individual’s health is determined by a range of factors * Evaluates aspects of health over which individuals can exert some control * Describes factors that contribute to effective health promotion * Proposes actions that can improve and maintain an individual’s health * Forms opinions
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