Unit 4 Case Studies. 1000w. due 3-30-23
Instructions
- Identify a friend, peer, or family member you can interview to collect complete and comprehensive subjective and objective data sets, as though they were a new patient in your office for an annual wellness visit or establishing as a new patient to the practice.
- Conduct an interview and physical exam.
- Document your findings in a Word file. Structure the subjective and objective data sets in the format provided in your lecture materials.
- Submit the Word file containing your data sets into this .
Subjective Data
20 pts
Highly Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented (all 9 elements are correctly documented)
Objective Data
20 pts
Highly Proficient
Elements of objective data are adeptly documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
The assessment should look like this one with all the subtopics and this much details. Just use a different patient with different health problems. Thanks.
NU610 Comprehensive Assessment
Subjective:
CC: Annual wellness visit
HPI: 28-year-old Caucasian female presenting today for an annual wellness visit. Patient is
relatively healthy. Patient states she has most recently started experiencing anxiety and feeling
stressed because of work, managing children, and finances. She is short with her children, 3
kids. One set of twins who are 6 months old and 1 3-year-old daughter. Per patient, “I have
mostly good days but don’t like being short with my kids.” Patient does state she has no history
of mood disorders. Patient does not ever feel so low she feels like harming herself.
PMH: Unremarkable history. Two vaginal deliveries without complications. No hospitalizations
are noted other than for giving birth. No surgical history. Patient takes melatonin occasionally to
help her sleep but states she doesn’t think it really does much for her.
Allergies: NKA
Medications: Melatonin 5mg PRN for sleep assistance; Womens prenatal vitamins
Social History: Patient is a registered nurse at an ambulatory surgery center. She is married to
her husband and they share 3 children together. She is currently breastfeeding her 6-month-old
twins. Socially drink, maybe once a month 1-3 glasses of wine. Denies smoking or use of illicit
drugs. States she tries to eat healthy but can always do better. She does not routinely excise.
She enjoys camping in her free time with family.
Family History: Maternal grandmother recently died at age 95, she did have HTN but rarely went
to the doctor or followed through with medication regimens. Maternal grandfather died when she
was younger from a heart attack unsure of what his age was when he passed. Paternal
grandmother still alive and doing well at assisted living at 96. Paternal grandfather died also
when she was younger, believed to be in his 60s and unsure of what he died from. Parents are
both still alive. Both have HTN and HLD. Mom recently started on antianxiety medication PRN.
Health Maintenance/Promotion/Immunizations: Patient attends biannual dental cleanings and
annual wellness visits. She also sees her eye doctor annually. Up to date with immunizations
per patient. She does receive the annual flu shot and has had two COVID-19 shots but no
boosters. Does not show interest in being boosted today. Will request health records from the
prior provider as we are establishing care together. Discussed together the recommendation to
consider the HPV vaccination per USPSTF guidelines. She does not remember receiving this
when she was younger.
ROS:
General: Denies fever, chills, fatigue, malaise. Denies any recent change in weight.
Skin: Denies any new moles, raised areas, skin discoloration. States she uses sunscreen
regularly.
HEENT: Denies history of head injury, no recent headaches. No vision changes, does not wear
contacts or glasses. Denies any hearing changes, tinnitus, or vertigo. Denies nasal congestion,
sinus pressure/pain. No pain or difficulty with swallowing, no tooth pain. Has never noticed
lumps or abnormal swelling of glands the patient is aware of.n:
