Describe the relevant information related to the chief complaint (symptom analysis).

Practice your skills in developing a therapeutic partnership with your patient.
Obtain and build, in collaboration with the patient, a comprehensive health history.
Develop a comprehensive health risk assessment based on the data you have collected and analyzed.
To complete this assignment, you will interview a volunteer patient and document a comprehensive health history using the guideline provided. You will not perform any kind of physical examination; all data will be subjective in nature. You will analyze the data you have collected and compile a list of health problems and risk factors.

Your patient should be at least 50 years old and have at least one chronic health problem.

Guidelines
Use the document provided below to gather a comprehensive health history.
Your document should be formatted in a manner that is consistent with a standard medical record rather than in essay form.
Be sure to address all points under the provided headings.
The HPI should be written in a narrative format.
Other sections may include bulleted points or brief statements.
The Review of Systems should follow the standard format, as illustrated in the textbook.
In your final draft, be sure to remove the italicized instructions that are provided in the document.

Assignment Guideline

The purposes of this assignment are to:
practice your skills in developing a therapeutic partnership with your patient
obtain and build, in collaboration with the patient, a comprehensive health history
develop a comprehensive health risk assessment based on the data you have collected and analyzed

To complete this assignment, you will interview a volunteer patient and document a comprehensive health history, using the guideline provided. You will not perform any kind of physical examination; all data will be subjective in nature. You will analyze the data you have collected and compile a list of health problems and risk factors.

Your patient should be at least 50 years old and have at least one chronic health problem.

Use the guideline below to gather the comprehensive health history. Your document should be formatted in a manner that is consistent with a standard medical record, rather than in essay form. Use the headings that are provided below to create an outline format, and be sure to include all the listed sections. Under each section, be sure to address all the suggested points. Do not include any of the instructions provided in this guideline. The HPI should be written in narrative format. Other sections may include bulleted points or brief statements. The Review of Systems should follow the standard format, as illustrated in the textbook.

Reason for Visit, the chief complaint (cc): Date of History:
Patient Profile:
Patient Initials:
Age:
Gender:
Marital Status:
Ethnicity/Country of Origin/Race:
Language:
Education level:
Religion (optional):
Occupation:
Health insurance status:
Source of History and reliability of source

Health Status or History of Present Illness (HPI): HPI refers to the recent changes in health that led the patient to seek medical attention at this time. Describe the relevant information related to the chief complaint (symptom analysis).

If the patient does not present with a problem, or presents for a routine health history, you should ask about the date of their last health assessment, and ask the patient to discuss any pending issues from the last exam (e.g. abnormal lab results, previous patient education related to diet or to exercise, advice regarding preventive health measures, etc) and to explain the current status of those issues. Ask how the patient would rate his/her health, and why. In addition, you should address any chronic illness the patient has, asking about current symptoms, adherence with diet, medication, etc. Finally, if you discover any significant positive symptoms in the Review of Systems, you should include those in the HPI, using the OLDCARTS model to gather additional information about the symptom.

OLDCARTS
Onset When did it start? Did the problem come on sudden or insidiously? Location Where on/in the body is the problem occurring? Radiation?
Duration How long have you been having this problem? Have you had this problem before?
Characteristics Description of the problem.
Aggravating or Associated Factors – Does anything accompany the problem? Is the concern related to some other event? What makes the symptom worse?
Relieving Factors – What makes it better? Home remedies, herbal, vitamins, over- the-counter, prescription medications, diet, activities
Temporal Factors – Time of Day? Consistent? When does problem come and go?
Severity Can you rate the severity on a scale of 1 to 10? Has the problem affected you so much that you are no longer able to go to work or school? Does the problem prevent you from doing any of your regular routine activities?

The HPI should be written in narrative form, rather than bullet points.
Past Medical History (PMH):
Be sure to indicate dates or ages of illnesses and procedures, if known. Write the PMH in bullet format, rather than as a narrative.

Childhood Illnesses:
Measles
Mumps
Rheumatic Fever
Polio
Rubella
Pertussis
Scarlet Fever
Chickenpox (varicella)
Frequent otitis media
Others

Adult Illnesses: Psychiatric Illnesses: Accidents and Injuries: Operations Transfusions:
Additional Hospitalizations:

Family Medical History: Include at least three generations, noting age of diagnosis or death for each illness, as known. Explain any missing data (e.g. adoption, unknown history of a relative). This section should be a genogram. Create a detailed pedigree diagram that includes all diagnoses with respective ages.

Allergies: (food, medication, environmental). Note how the allergy is manifested. Use bullet format.

Current Medications: (Includes prescribed medications, nonprescription drugs, herbal or home remedies, vitamin/mineral supplements, medicines borrowed from family members or friends). Use bullet format, and include dosage and frequency for each medication.

Immunizations: Include dates or age of administration. Use bullet format.

Screening Tests (for Health Maintenance): Ask about the frequency of the following exams (ass appropriate for your patient), the date of the last exam, and the results. Use bullet format.
Physical Exam
Dental
Vision
Hearing
Mammogram (Female)
Pap smear (Female)
Digital rectal exam of prostate, PSA (male)
Fecal occult Blood/Fecal Immunochemical Test/colonoscopy/sigmoidoscopy
PPD/TB Screen
Other targeted screening based on occupation or other personal risk factors (Antibodies or titers related to infectious disease/immunization status, such as MMR, Hep B, Hep C, HIV, etc)
Home environment:
Home (age of the home, concerns about fire, stairs, adequacy of heat and cooling, pest control, space, smoker in the family, source of water, hazards such as asbestos or lead-based paint, privacy issues)
Usual mode(s) of transportation (driving car, walking, motorcycle, bicycle, public transport)
Neighborhood/Community (availability of stores, market, laundry facilities, drugstore, access to alternative transportation if needed)
Safety of the neighborhood
Use brief statement format.

Exercise and Leisure Activities:
Exercise (amount, time, and frequency); ideas on efficacy of exercise
Recreational activities
Amount of sun exposure
Use brief statement format.

Use of Safety Measures: Seat belts, helmets (bicyclists and motorcyclists), car seats for children, sunscreen, condoms, handrails in bathtub, etc
Use brief statement format.

Sleep Patterns: Number of hours per night, regularity of sleep patterns, use of sleep aids, attention to sleep hygiene, daytime sleepiness

Use brief statement format.
.

Nutritional Screen: Gather and document a 24-hour recall.
Known dietary restrictions
Dietary supplements used
Known risk factors for eating disorders
Risk factors for food/medication interactions

Weight: Stated weight and height. Perception of ideal weight, attainable weight; methods of weight management
Use brief statement format.
Family:
Members of current household (Use the table below as your format):

Name Gender Age Relationship Occupation or school grade Health status Other pertinent
on-going issues

Name and relationship of emergency contacts and contact information:

Occupational History: Type of work performed. Sedentary occupation. High-stress occupation. Working at heights, at/near moving objects, on slippery surfaces, in high temperatures, with electricity, with hazardous materials. Military history, including exposure to traumatic events

Use brief statement format.

Financial Status/Source of Income:
Use brief statement format.

Health Insurance Status: Use bullet or brief statement format

Advance Directives: Living will, Five Wishes, Power of Attorney, POLST/MOLST forms
Use bullet or brief statement format.

Recent Life Chan ges or Stressors (divorce, new job, family illness, relocation)
Use bullet or brief statement format.

Patterns of Coping with Stress: including use of medications, support groups, religion, spirituality, yoga, meditation, etc.

Use bullet or brief statement format.

Screening for Possible Physical/Mental Abuse/Neglect: Use appropriate screening tools, such as HITS, from your required textbook or the asynchronous lecture on interviewing for the health history. Document positive and negative responses to your specific screening questions.
Use bullet or brief statement format.

Functional Ability: (When relevant, older or disabled persons)
Activities of daily living (ADL) such as bathing, feeding, dressing)
Instrumental activities of daily living (IADL) such as shopping, cooking, doing errands
Use bullet or brief statement format
Substance Use: Ask about tobacco (including vaping), alcohol, recreational drugs. Include duration of use, frequency, amount, previous attempts to quit. Use appropriate screening tools, such as CAGE, from the required text. Document positive and negative responses to your specific screening questions.

Use bullet or brief statement format
Sexual History: Ask about the Five Ps as described in your required textbook: Partners, practices, protection, past STIs, pregnancy plans. Be sure to ask permission from the patient before asking questions, assure the patient of confidentiality, and use a non-judgmental approach, as described in your textbook.

Use bullet or brief statement format

Contraceptive History (Use the table provided below):

Time Period Contraceptive Type Problems? Reasons for Change

Reproductive & Gynecologic History: Women (Use bullet format, along with the provided tables):

Menstrual History:
Menarche Length Frequency
Amount LMP
Pain Bleeding Between Periods
Amenorrhea Premenstrual Symptoms

Gravida Para Elective Abs Spon. Ab

Maternal Obstetrical History:

Gravida Para: F P Elective ABs Spon. ABs L.C.

Hx. Preg. 1 2 3 4 5
Date pg. end
Wk. Gestation
Month care started
Total wt. gain
Hrs. in labor
Del. Type
Place of del.
Attendant
Babys sex
Birth wt.
Infant probs. *
Maternal problems **
Other comments

< 5 1/2 lb. ** Pregnancy-induced hypertension > 9 labs. Eclampsia
Need for resuscitation Incompetent cervix
Genetic disorder Antibody incompatibility
Birth defects Rh Ng RhoGAM given?
Genital herpes
Other medical conditions

Infertility:
Perimenopausal Period:
Changes in menstrual pattern
Data of last menstrual period
Associated symptoms (hot flashes, night sweats, mood swings, difficulty sleeping, etc)
Impact on daily functioning

Reproductive History: Men (Use bullet format)

Contraceptive Methods: Number of Children:
Infertility:

Review of Systems (ROS):
Significant positive answers must be analyzed as symptoms and included in the History of Present Illness.
Use brief statement format, as shown in your textbook. Use headings for each system.

Constitutional: Fever, chills, Changes in weight, change in fit of clothes, weakness, fatigue, night sweats.
Skin: Changes in your skin, hair, nails. Rashes, sores. Lumps, itching, pain

Head: Headache (Assess its chronological pattern and other attributes); Lesions
Eyes: Visual acuity, corrective measures. Pain, burning, itching of eyes or surrounding area. Redness, tearing/watering, diplopia
Ear: Hearing acuity, corrective measures. Tinnitus, vertigo, ear pain or feeling of fullness/pressure, ear discharge, excessive cerumen, use of swabs to clean ears, medications. Sustained exposure to loud noise
Nose and Sinuses: Rhinorrhea, nasal stuffiness, epistaxis, medications frequently used. Decreased sense of smell.
Mouth and Throat: Lesions on lips or in the mouth, dental caries, bleeding from gums, sore tongue, hoarseness, sore throat

Neck: Swollen glands or lumps in the neck, goiter. Pain or stiffness in the neck.

Breasts (applies to both male and female patients): Pain or discomfort, lumps, discharge from the nipples, skin changes, redness. Frequency and timing of breast self-examination.

Chest/Respiratory/Cardiac: Pain or discomfort in the chest, palpitations, dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, wheezes. edema, cough (with description), hemoptysis

Gastrointestinal: Dysphagia, pain on swallowing, heartburn/indigestion, regurgitation, excessive belching, abdominal fullness after meals or inability to finish eating meals. Nausea and vomiting, abdominal pain, anorexia, excessive flatulence. Frequency of bowel movements, appearance and color of stool, constipation, diarrhea. Corrective measures for any of the above.

Urinary: Kidney/flank pain (pain at or below costal margin posteriorly), pain on urination,urinary urgency, urinary frequency, nocturia, urinary hesitancy/straining to void, reduced caliber and force of urinary stream, dribbling, incontinence. Color of urine, hematuria.

Genitalia:
Male Discharge from penis; sores or growths on the penis; swelling or pain in the scrotum; sexually transmitted infections related questions; oral/anal sex; diarrhea, rectal bleeding, anal itching or pain, sore throat; sexual history (if not previously explored) impotence; hypoactive sexual desire disorder

Female Bleeding after intercourse or douching; pin with intercourse, vaginal discharge.

Peripheral Vascular: Pain in the arms and legs, swelling of the feet and legs, redness, tenderness, coldness, numbness, intermittent claudication. Any corrective measures for above.

Hematologic: Frequent or easy bleeding or bruising, nosebleeds, medications (e.g. aspirin, blood thinners; Vitamin C or Vitamin K deficiency (inadequate diet, malabsorption).

Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerance, sweating. Preference for hot or cold weather, perspiring more than others or needing more blankets, sweaters/coats more than others.
Musculoskeletal: Pains in joints and associated symptoms; swelling; limitation of motion (including limitation to activities of daily living); tenderness; warmth; redness; symptoms elsewhere associated with joint pains; backache. Muscle weakness (generalized or localized; relation to certain activities)

Neurologic: History of loss of consciousness, syncope/near syncope. Seizures or spells. Weakness or paralysis of any part of the body. Tremors and other involuntary movement. Pain. Paresthesias.

Mental Status and Psychiatric Symptoms: Problems or changes in orientation to time, place, and person; level of consciousness; understanding questions and responding appropriately; change in speech, grooming, or personal hygiene. Change in sleep pattern. Getting lost when driving to a familiar place. Suicidal ideation (with appropriate follow-up questions if positiveinclude these in the HPI)

PROBLEM and RISK ASSESSMENT LIST

After you have obtained the comprehensive health history for your patient, review all of the data and construct a Problem and Risk Assessment List. The list should be holistic to include:
Firmly Established Diagnoses (chronic diseases or current urgent needs)
Allergies
New Symptoms (C/C, HPI, ROS)
Preventive Care (Doing or Needs to be Doing)
Abnormal Findings/Lab Data (as reported by the patient)
Risk Factors related to safety, occupational exposures, genetic factors,
Personal Difficulties (Social, Family, Personal, Financial)
Educational or Anticipatory Guidance Needs
Advance Directives
Deficits in Functional Status (ADLs, Incontinence, Mobility)
Past medical history items that may impact future risks (e.g. history of chickenpox, with future risk of herpes zoster; history of gestational diabetes; history of tobacco use). For each of these you may have, in addition to a date of onset/date of identification, a date the problem was resolved.

Format your list as seen below. Remember that this is a list of problems or risk factors. It should not include any interventions, such as medications to be prescribed. It should not include a narrative.

Problem and Risk Assessment List

Problem or risk factor Date of onset or date identified Date resolved

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