For this week’s assignment, you are going to find a patient with an acute CC. Complete a History and Physical (H&P) on a patient with an acute complaint.

The Acute History and Physical

Instructions:

1. Complete all of the readings up to and including Week 5.

2. For this week’s assignment, you are going to find a patient with an acute CC. Complete a History and Physical (H&P) on a patient with an acute complaint.

3. Pick one of the acute chief complaints (CC) below. You must post the CC you are going to write about by Monday of Week 5. If you have a CC that you want to use that is not on the list, please get approval from the instructor. Be sure to check the posts of other students to avoid duplication of topic. You may choose a CC from the organ systems that we have reviewed up to and including Week 5.

Sore throat
Wheezing
Hoarseness
Earache
Ringing in ear
Ear drainage
Nasal symptoms and congestion
Difficulty swallowing
Red eye
Eye drainage
Rash (there are MANY – look up types of rashes)
Skin eruption (there are MANY – look up types of skin lesions)
Cold sore
Calf pain
Purple hands/cold hands/feet
Acne
Cellulitis
Racing/fast heart beat
Chest pain
Pain in sinuses/face pain
Cough
Bloody phlegm
Green phlegm
Shortness of breath
Difficulty swallowing
Limb pain and/or swelling (not due to an injury/trauma)

4. Document subjective data: (Include Identifying data – age, gender)

Chief complaint (CC) – must be in patient’s own words – use quotation marks

History of Present Illness (HPI) – Include a symptom analysis for CC using the OLDCART acronym. List the HPI using each term of OLCART for practice and clarity as follows:

Onset:
Location:
Duration:
Characteristics:
Aggravating factors:
Relieving factors:
Treatments:

Past Medical History (include date of diagnosis)

Past Surgical History (include year of surgery and any complication)

Family History (FH): Include only the FH that would contribute to the development of the differential diagnoses for the CC.

Social History (SH): Include only those components that will contribute to the development of the differential diagnoses for the CC. Be sure to include employment, type of dwelling and whom patient lives with.

Medications, OTC, supplements

Allergies (medications, food, other) and reaction

Review of Systems (ROS): Include systems related to CC as well as constitutional ie nausea, vomiting, diarrhea, weight loss, weight gain. Follow ROS template provided. The ROS is NOT the same as PE. Use term denies or patient states… for negative or positive responses to questions, respectively. If there are positive findings in any system, you must inquire using OLDCART and document accordingly.

Explanatory Model: Use BATHE Technique

5. Document objective data to include:

Vital signs:

General Survey:

PE: Examine only those organ systems that are pertinent to the CC but always assess respiratory and cardiac systems on all patients. The PE is not the same as ROS; is a hands-on head to toe assessment performed by the provider. You will not be performing a genitourinary examination for this assignment. Use textbook – follow proper written documentation verbiage. Use the IPPA (Inspection, Percussion, Palpation, Auscultation) and document your findings as a chart worthy document.

6. Pick one possible diagnosis.

7. Identify one diagnostic study (lab, x-ray or maneuver) that will help to confirm the diagnosis you have chosen. Cite and reference your work using a clinical guideline, peer reviewed article, textbook, or other reputable source as evidence from the literature. Look for the “gold standard” diagnostic study to confirm the diagnosis.

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