Complete Health History Sample Essay

Complete Health History Sample Essay

Write-up complete health history on a selected person of your choice, citations in the diagnoses section and the treatment plan section.
Use the history components of the SOAP note to guide you.
I\’d like the hypothetical person to be a 32-year-old male, no past medical history, only complaint constipation.

Complete Medical History

Patient’s ID: Mr. A

Physical and History conducted by: Dr. P

Physical and History conducted on: March 10, 2018

Chief Complaint: “I am okay most days, except that I have regular constipation that is very irritating and for which I have to take laxatives.”

Past Medical History: No past medical history.

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HPI: 32-year-old male. He has been treating his constipation using over the counter laxatives without a prescription. His follow up in the clinic has been occasioned by the on and off constipation that is not solved by over the counter laxatives Complete Health History Sample Essay.

Review of Systems:

General: No night sweats or fever.

Skin: Normal baldness pattern due to aging with no changes to the skin.

Head: No history of seizures, dizziness, trauma, headaches, or trauma.

Eyes: No field or vision changes, or glaucoma diagnosis.

Ears: No vertigo or tinnitus.

Nose: No running nose, facture history or epistaxis.

Mouth and Throat: No pain or sores.

Neck: No pain, goiter or masses.

Respiratory: No hemoptysis, sputum, wheezing, or cough.

Gatrointenstinal: No black stools, diarrhea, vomiting or nausea. Persistent constipation that occurs at least once weekly for which he takes over the counter laxatives. The constipation is accompanied by abdominal pain. Complete Health History Sample Essay.

Genitourinary: No urination urgency or frequency, or dysuria.

Neurologic: No paresthesia, tingling or numbness.

Musculoskeletal: Occasional abdominal pain but no joint or muscle pain.

Hematologic: No history of transfusion, anemia or bleeding disorder.

Emotional: N history of abnormal adjustments, depression, or psychiatric problems.

Family History:

Father 82, Obesity, Hypertension

Mother 76, Rheumatoid arthritis

Sister 42, History of breast cancer

Physical Examination:

General Appearance: Oriented and alert 32-year-old male in no acute distress.

Vital Signs: BP 127/77 HR 70 RR 15 Weight 174lbs Height 6’1/4” Temp not measured

Skin: No abnormal lesions or moles noted.

Neck: No masses.

Cardiovascular: Regular rhythm and rate, no gallops, rubs or murmurs.

Lungs: No crackles or wheezes.

Abdominal: Abdominal pain, soft and no striations, scars or distensions. No pulsatile masses. Liver and spleen are not palpable. Complete Health History Sample Essay Murphy’s sign is negative with no guarding or reflex tenderness.

Rectal: Negative hemoccult.

Problem list: Persistent constipation.

Differential diagnosis:

Constipation, abdominal obstruction

Discussion:

Mr. A reports constipation with all other signs being normal.  As such, there is a need to recommend medication for constipation.

In addition, intestinal obstruction should be considered. That is because it can add to the persistent constipation to cause the abdominal pain (Tham, Collins & Soetikno, 2016).

Diagnostic plan: Abdominal tests to check for obstructions that could cause the constipation.

Therapeutic plan:

Complete Health History Sample Essay The constipation should be treated by prescribing docusate sodium BID (a laxative).

Patient Education: Mr. A should be educated on the need for proper diets, rich in fiber, and exercise.

 

References

Tham, T., Collins, J. & Soetikno, R. (2016). Gastrointestinal Emergencies (3rd ed.). Hoboken, NJ: John Wiley & Sons Complete Health History Sample Essay.

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