Advanced Health Assessment
Instructions: Type patient encounter information directly into each box of the template. Students should avoid the use of the
... [Show More] following terms:
“WNL”/”Normal”, etc and should document systems with sp
have provided on previous cases into each subsequent assign
CC: 49-year-old female
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes”
“Exertional mid-chest pain that radiates to
left arm with a squeezing quality”
HPI: pertinent s/s; +/- ROS/prior episodes/recent
travel/ill contacts
PMHx child/adult
illness/hospitalizations/immunizations History of
hypertension and high cholesterol
Missed this year’s flu vaccination
Location: Mid chest that radiates to left
arm
ecificity and accuracy. Students are also expected to incorporate any feedback faculty
ment.
Ms. Barnes is a 49-year-old female with chest pain and dyspnea that started 2
weeks ago during a ski run activity in the cold. She reports that the chest pain
radiates to the left arm and has a squeezing quality to it. The pain is
exacerbated by fast walking in the cold and relieved by resting.
Onset: Chest pain 2 week ago during a cross-country ski run
Duration: The chest pain comes and goes. Lasts several minutes and occurs1-2
times a week
Character: Chest pain with a squeezy quality and radiates to the left arm. Pain
scale of 5 or 6 on scale of 1-10
Aggravating/alleviating factors: Precipitated by exercise and improves with
rest
Related symptoms: Dyspnea that occurs with chest pain with exertion
Case: 165484 Karen Barnes Date:
Treatments: Nothing Father died at age 65 of stroke
Significance: Chest pain in someone with
her medical and family history can indicate
a serious problem
SurgHx type/when/why/complications
No surgical history
FamHx
Mother died at age 54 with heart disease
Older sister age 58: recent open-heart surgery SHx
Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships
ETOH: Drinks 1-2 glasses of wine each night
Tobacco: Previous smoker: Quit 15 years ago
Denies use of recreational drugs
Grandparents (if known)/Parents/siblings/children
Reproductive Hx
Female: Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hx/sexual hx
and concerns/LMP/menopause
Breast/cervical screening (if any) Male: Sexual hx
and concerns/issues with fertility (if any)/Testicular
or prostate screening (if applicable) Screening for
STI’s (if applicable)
Up to date for cancer screening for gender.
Annual gynecological exam normal
Not currently sexually active
Patient reports a very stressful job
Allergies (Food, Drug, Environmental, etc.)
No known allergies
List of Medications/supplements (prescription, OTC, complementary
alternative therapies)
Hydrochlorothiazide 12.5mg daily
Review of Systems: (ROS) Use this column to
document the ROS below.
General: Chest pain with dyspnea, denies
fatigue, weakness, sleep disturbance HEENT:
No complaint of headache, vision problem,
ear pain or sinus problems Pulmonary: shortness of breath with exertion,
denies wheezing
From the ROS: list/highlight the current symptoms/complaints to generate a
list of pertinent “reported or denied” symptoms below:
Case: 165484 Karen Barnes Date
Pertinent Positive ROS: Chest pain middle
chest that radiates to left arm, history of
hypertension and high cholesterol, Dyspnea
with exertion
Pertinent Negative ROS: Denies wheezing, or
recent change in sleep pattern, denies change
in diet, no complaint of
nausea/vomiting/diarrhea or change in
Case: 165484 Karen Barnes Date:
No complaint of
No complaint
no complaint of dizziness, fainting,
Case: 165484 Karen Barnes Date:
No visible scars or deformities or lesions
Case: 165484 Karen Barnes
GI: abdomen not tender and bowel sounds present
in
all 4 quadrants GU: negative for any
urinary problems
LDL cholesterol
Blood glucose: normal
Cardiac stress test: ST segment depression Echocardiogram: Normal cardiac
structure and function CK-MB: Normal
Neuro: Alert and oriented X 4 Derm: Skin turgor
normal. Skin warm and dry with no lesions
MSK: Normal bulk and tone Psych:
Not assessed
Lab/Radiology or other Diagnostic data: 12
lead electrocardiograms: Normal sinus
rhythm, no ST elevation abnormalities
Troponin T: within normal values
CBC: all labs within normal values
Lipid profile: elevated cholesterol, and elevated
IHUMAN TOTAL CASE SCORES:
#1: 71%
#2: 95%
Based on patient’s age/risk factors, what
Problem Statement:Ms. Barnes is a 49-year-old female with chest pain and
dyspnea that started 2weeks ago during a ski run activity in the cold. She reports
that the chest painradiates to the left arm and has a squeezing quality to it. The
pain is exacerbated by fast walking in the cold and relieved by resting. She has a
history of hyperlipidemia and hypertension. She has a previous history of
smoking and a family history of coronary vascular disease. She is slightly
overweight; the remainder of exam is unremarkable. Physical examination
indicated elevated BP. EKG is normal with no ST elevation abnormalities.
Troponin, CBC, lipid profile, CK-MB were normal
Cervical cancer screening for women aged 2165 years
Grade B RecommendationsScreening for Depression/Mood Disorders in adults
List the (reports stress at today’s visit)
differential diagnoses (Must
Miss/Leading/Alternate/Concluding)
*Include ICD 10 codes after each preventive scre
would be recommended at today’s or a future vi
not
Healthy diet and physical activity for prevention of CVD in
ening adults with risk factors Skin Cancer prevention annually
sit:
Screening for unhealthy alcohol/drug use in
Grade A Recommendations:
High Blood Pressure adults over age 18. Check periodically
for evidence of elevated b/p readings (slightly elevated b/p
likely related to pain) [Show Less]