Pulling It All Together

The written comprehensive history and physical assessment is to be performed on a relatively healthy individual with at least one well-managed health alteration, such as high cholesterol, diabetes, or heart disease. Keep in mind that the focus of this assessment is to learn how to perform appropriate techniques on a medically stable individual, and so it is best to choose someone you know, rather than a sick individual in a clinical setting.

For more detailed explanation of the components of this assignment, refer to Chapter 28 of the course textbook entitled Pulling It All Together. Be sure to follow the grading rubric from the syllabus as a checklist. The Review of Systems (ROS) and Physical Exam (PE) that should be included in this assignment are as follows: skin, hair, nails, head, neck, ears, eyes, nose, mouth, throat, sinuses, thorax, lungs, heart, neck vessels, peripheral vascular system, abdomen, mental status, musculoskeletal and nervous systems.

For the following, please list only the expected normal findings – DO NOT perform exams on breasts and regional lymphatics, anus, rectum, prostate, or genitalia. This assignment should be approximately 10 double-spaced and typed pages, according to APA format. Appropriate terminology and a complete description of normal and abnormal findings should be well documented.

 

Comprehensive Health History and Physical Assessment

Please attach the table below to your completed H & P on the last page. Here is a link to a document containing the table.

 

Point Allocation for the Paper	Points
Chief Complaint and History of Present Illness	5
Past Medical, Surgical, and Social History	10
Family History List of Risk Factors (include Modifiable and Non-Modifiable)	10
Review of Systems	10
Functional Assessment & Nutritional Assessment	5
Physical Exam	15
Conclusion Including List of Normal and Abnormal Findings, and Plan with Recommendations	20
Format and Grammar	5
Total Points Possible	80