Health History and Physical Assessment Write-Up, powerpoint presentation help

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Title: Complete Health History and Physical Assessment Write-Up Power Point Presentation

I’ve done the complete health history and physical assessment on the patient already, do not change my information, but you can correct and add to the narrative for me please to make it more professional.

I need you to put it into power point slides for me.

Use this patient and create a professional Microsoft PowerPoint presentation with narrative slides.

Completing the PowerPoint presentation with narrative slides:

The health history and physical assessment presentation will utilize the detailed health history and physical assessment you completed.

You are to develop a professional PowerPoint presentation with narrative slides that covers the complete health history and physical assessment.

You can use the power point sample that I sent to you as an example but I want a different PowerPoint design presentation.

Keep in mind that this is a professional presentation.

As you are completing the PowerPoint presentation you will need to add more narrative to the slides for me please.

The narrative should be added under each slide in the PowerPoint presentation.

FYI This is the rubric Grading Criteria, make sure you cover every single point please

Developed a professional PowerPoint that covers all major topics in the Health History and Physical Assessment Form.

Include narrative for each slide (at bottom of slide) of the presentation.

Presented the Health History and Physical Assessment in a professional manner using correct medical terminology.

Lead discussion with appropriate answers and questions to presentation.

Used correct spelling, grammar, and professional vocabulary. Cited all sources using the correct APA style. References cannot be any older than 5 years

This is the patient’s information

Name: V.A Date: 07/12/2017 Time: 11:00 AM

Age: 22 Sex: Female

SUBJECTIVE

Chief Complaint: 22 years old female complains of ”Memory lapse, confusion, Headache , disorientation, unsteady at time and dizziness, ringing in ears subsequent to head injury 3 weeks and a couple of days ago and requesting for referral to go to a neurologist”

History Of Present Illness: Female patient reported that she had head injury on 7/4/2017 due fall and hit the back of the head Patient reported to have memory lapse, confusion, Headache , disorientation, unsteady at time and dizziness, ringing in ears subsequent to head injury.

Medications: Meclizine for dizziness 25mg PO 3 times a day

Previous Medical History: Head injury 07/4/2017due to fall

Previous Surgical History: Wisdom teeth extraction

Allergies: Patient denies has no known medical, environmental or food allergies.

Medication Intolerances: None

Chronic Illnesses: Musculoskeletal

Indicates having chronic pain in the lower back, hypotrophy, numbness in right arms radiating down into hands, fingers do to MVA, no other muscles, joint pain or swelling, no parenthesis or any numbness and fracture L4-5 2* MVA at age 18

Major traumas: patient denies chronic illness and chronic illness

Hospitalizations/Surgeries Hospitalization only 07/4/2014 and when has the motor vehicle accident 3 years ago

Family History

Maternal: Have CAD and HTN

Paternal: Healthy

2 brothers alive and well

Grand-parents on both sides diagnose to CVA, HTN, open heart surgery, lung cancer

Patient denies family and sibling diagnose with psychiatric illness, kidney disease, tuberculosis, neither diabetes mellitus nor kidney disease.

Social History

Single, female currently leaving alone with 19 month old son, works as a manager at Tijuana flat restaurant .She is a high school graduate student. She is occasionally drinking alcohol. She reports that she smokes 1 pack of cigarette

Nutrition History Mostly eating healthy.

Review of System

General

No weight change, no change in strength. Patient denies fatigue, fever, chills, night sweats. Cardiovascular

Denies Chest pain, palpitations, edema, history of syncope nor orthopnea

Skin

Bruising on arm due to rough sex as per patient stated, no rashes, bleeding, lesions, abnormal pigmentation or skin discolorations,

Respiratory

No Cough no wheezing, no hemoptysis, no dyspnea, no history of upper and lower respiratory disease

Head: Headache, dizziness, vertigo, head injury on 7/4/2017 due to fall, hitting back of the head.

Eyes

Normal vision, no diplopia, no tearing nor pain, no blurring.

Gastrointestinal

No abdominal pain, skin is normal, no distention on inspection, no bowel pattern change, no tenderness, no mass, it is soft when palpate, bowel sound present on all four quadrants when auscultate, no sign of emesis, melena, no change in appetite.

Ears

She indicates of feeling ringing in the ears, Tinnitus, no change in hearing, no bleeding, no ear pain, hearing loss no discharge

Genitourinary

Gynecological . She indicates have the pap done last year

No urinary urgency, no dysuria, no frequency, no burning, no change in color of urine, no vaginal discharge no contraception, sexual active with one partner,, no sign of Sexual Transmitted Diseases noted nor reported, no change in menses, no dysmennorya, no pelvic pain, no mammogram , but perform self-breast exam every month after her monthly menstrual period and had 1 pregnancy and one child alive and leaving well.

Nose no epistaxis, no obstruction nor discharge

Mouth no dental bleeding, no cavities

Throat no complain of pain, no lesion, uvula are raise and fall, no lesion noted.

Neck No stiffness, no pain, no tenderness, masses

Musculoskeletal

Indicates having chronic pain in the lower back, hypotrophic, numbness in right arms radiating down into hands, fingers do to MVA, no other mucles, joint pain or swelling, no paresthesia or any numbness and fracture L4-5 2* MVA at age 18

Breast

No lumps, no tenderness, no swelling, no skin discoloration

Neurological

Changes in mentation, ataxia at times, no sweat no syncope, no seizures, no transient paralysis, no weakness, paresthesias, black out or spells.

Heme No sign of skin bruising noted and able to tolerate normal environment temperature

Lymph No sign of swollen lymph node noted

Endorine

No sign of polydipsia, polyphagia, no polyuria or tachycardia reported

Psychiatric

Patient reported changes in sleep habits, no depressive symptoms, no changes in though condition, denies any history of suicidal ideation thought

OBJECTIVE

Weight 140 lbs BMI 23.30 Temp 97.3 F BP 119/70 mmhg

Height 65 in

Pain Scale 4 on 0-10 Pulse 73 bpm Resp 18 bpm

O2 Saturation 97% at room air

General Appearance: Alert and oriented healthy adult female appears well and no apparent acute distress.

Skin is normal color, write warm, dry, clean no rashes or lesions noted, red bruises observed on right upper arm. Patient stated “It happened is from having rough sex”.

HEENT

Head: is normocephalic, atraumatic and without lesions; scalp is moist, hair evenly distributed.

Eyes: Vision is normal, pupil are equal and reactive to light, non inicteric sclerae.

Ears: Tinitus No lesions, no tenderness fluid noted at the ear canals. It looks patent. Bilateral ears tympanics membranes appear normal without sign of infection

Nose: is clear, bilateral nostril is symmetrical, no swollen of turbinates, sinuses non tender to palpation, hair is evenly distributed, nasal mucosa pink and moist,

Neck: Supple. Patient able to move neck without difficulty, no pain, tenderness, mass, lumps, swollen gland, carotid pulse present, no sign of trachea deviation noted , no jugular vein distention or bruit.

Oral mucosa pink and moist, no sign of swollen, bleeding gum noted

Chest: Symmetric, no chest wall tenderness.

Breast no mass, no skin changes, no tenderness, no skin changes, no galactorrhea

Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular S1, S2 normal with regular rate and rhythm. no S3, no S4 sounds, no murmurs. Capillary refill is less than 2 seconds. Pulses 3+ throughout. No edema noted.

Respiratory

Bilateral patient chest observe symmetrical, she is breathing normally, respiration is even regular and non- labored, lung sound are clear bilateral on all lung , no history of lung diseases reported.

Gastrointestinal Patient abdominal skin is warm to touch, soft, non- distended, no guarding, no tenderness to palpation on all quadrants, bowel sound present on all four quadrants on auscultation. Last bowel movement 7/12/2017

Breast is bilateral symmetrical, skin is warm to touch with normal color and appearance, no sign of mass , tenderness, no nipple discharge noted.

Genitourinary: and rectal exam deferred, but bladder is non-distended up on palpation and inspection.

GYN G2P1A1-LMP 6/24/2017 regular. Last Pap done in 09/1/2016 normal result

Back: Patient back shows no sign of spinal tenderness, no spasm, no sign of scoliosis noted and complain of pain voice. Patient was able to bend down and touch her toes and bend laterally touching her ankle without difficulty.

Musculoskeletal Hypertrophic to right upper extremity noted, no deformity, no edema, no tenderness, no complain of pain no effusion, noted. Bilateral brachial, radial, femoral, posterior tibialis and anterior tibialis pulses present. Patient was able to perform active range of motion of bilateral upper and lower extremities without difficulties

Neurological: Patient is awake, alert and oriented.

Cranial nerves unremarkable, patient’s gait is normal, speech is clear, sensory is normal to light touch and pin prick, balance is normal when patient standing, walking and bending inside of the office. Bilateral upper extremities power and tone are unequal.

Sensory normal to light touch and pin prick

Psychiatric

Patient awake, alert, oriented and verbally responsive, wearing a clean blue jean short with a write long sleeve T-Shirt, she has a white tennis shoes in her feet, speaks with normal voice and able to keep a normal conversation, keep eye contact, maintain good posture during examination time

Lab Tests

Urine culture and sensitivity, CBC, CMP ,Lipid panel, HbA1C, TSH, T4, Vit D. pending

Special Tests: Weber test to check for earing lost. Normal

Diagnosis

Differential Diagnoses

o 1-Hypotention

o 2- dehydration (ICD-10 )

No active chronic diagnosis

Acute diagnosis

Diagnosis: Headache (ICD-10 code784.0),

Dizziness (ICD-10 780.4)

Vaginitis( 616.11)

Ringing in bilateral ears (388.30)

Plan

Therapeutics

o Plan: Refer patient to neurologist

 Labs: CBC, CMP, Lipid panel, HbA1C, TSH, T4, UA, and Vit D.

 Medication: Meclizine 25mg po TID as needed diagnosis diziness

 NY statin ointment per vagina topical bid #1 tube dispensed.

 Diflucan 150 mg PO x1 dose, repeat in one week #2. Diagnosis Vaginitis

 Fallow up in 2 weeks after labs result and call the office for any concerns.

 Education: To eat low fat diet, low carb, low salt, exercise, no smoking,

 no drugs, no drinking, keep environment safe, helmet, wash your hands before and after eat, take medications, finish to use the restroom and so on

 Non-medication treatments: Educated patient to drink plenty of water, cranberry juice to help with infection.

Evaluation of patient encounter. Patient verbalized she will apply and the instructions that I gave her

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