Health Assessment Check-off Project
The Assessment of Health Status of a Patient through Thorough History Taking and Physical Examination
Physical Exam Documentation
Chief Complaint: Alice is a 45 year-old Caucasian female admitted with a complaint of dull back pain that is worse on exertion. Health Assessment Check-off Project
History of Present Illness: The pain started 3 days ago, is located at the back above the scapula, lasts for several minutes, is dull, is increased by exertion, and “the heart beats faster” when it occurs. She is not taking any treatment for it yet, but it incapacitates her.
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Past Medical History (Hx): Alice suffered pulmonary embolism three years ago.
Past Surgical History: She has no history of surgery.
Family History: Alice has a family history of diabetes and hypertension on her father’s side. Her mother also died from a massive heart attack (myocardial infarction). She was weighing 120 kilograms at the time of her death.
Social History: Alice is a retired barmaid. She smokes 1 packet of cigarettes a day but drinks only over the weekends. She is a divorced mother of two and is still sexually active with two partners. She has no history of sexually transmitted illnesses and rarely travels. Health Assessment Check-off Project
Allergies: Alice has no known allergies.
Medications: She is not on any medications currently.
Review of Symptoms by System: Her cardiovascular system (CVS) review reveals a high blood pressure of 140/98 mmHg. X-ray shows a slightly enlarged heart and her body mass index is 32. There is nothing remarkable on auscultation of both the CVS and the respiratory system. There is no swelling, tenderness, or limitation of the shoulder joint. All the other systems are unremarkable.
Physical Exam: Alice appears overtly obese and breathless even at rest. Her gait reveals subtle lumbar lordosis, but she is well dressed and clean. She is oriented in space, time, place, and person with a Glasgow coma scale score of 15. Apart from the grossly disproportionate waist circumference, she has nothing else that is remarkable from the other systems.
Assessment: An ECG done on Alice shows significant ST-segment elevation consistent with ST-elevation myocardial infarction (STEMI). Blood tests also show elevated troponin levels. Health Assessment Check-off Project
Treatment Plan: Urgent admission for percutaneous coronary intervention or PCI. Pain relief by multiple analgesics is a priority before the PCI procedure.
References
Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Philadelphia, PA: Wolters Kluwer.
The Regents of the University of California (2018). UCSD’s practical guide to clinical medicine. Retrieved from https://meded.ucsd.edu/clinicalmed/write.htm
UNC School of Medicine (2019). History-Taking and Physical Examination. Retrieved from https://www.med.unc.edu/medclerk/resources/cdim-sgim-guide/history-taking-and-physical-examinations/
Health Assessment Check-off Project
