History & Physical Assessment

A​‌‍‍‍‌‍‍‌‌‍‌‍‍‌‌‌‍‍‍‍​ 4-year-old is on albuterol MDI prn for rare episodes of wheezing. The family recently moved to an apartment where previous owners had a cat. The move has triggered daily wheezing for the past week. Based on NIH guidelines, what medications would be used? What can be done to help her? What is the relationship between allergens and asthma​‌‍‍‍‌‍‍‌‌‍‌‍‍‌‌‌‍‍‍‍​? Please address the above questions using APA format and then formulate a History & Physical for the above patient. Include an evidence-based plan of care. Please include at minimum one peer-reviewed journal article published within the past 5 years as reference. apa 7th

H & P GUIDELINES

Student Name: ________________________________ Date Submitted: _______________

When completing a H & P, consider the following issues:

History of
Present Illness

Includes a chief complaint
Appropriate dimensions of cardinal symptom are listed (including location, severity, quality, setting, chronology, aggravating/alleviating, associated manifestations)
Chronological story begins at baseline state of health
Incorporates elements of PMH, FH, SH that are relevant to story (e.g. includes risk factors for CAD for patient with chest pain)
ROS questions pertinent to chief complaint are included in HPI (not in ROS section)
HPI reflects knowledge of differential diagnosis
HPI narrative flows smoothly, in a logical fashion
Past Medical History Includes sufficient detail (onset, complications, and therapy) for key diagnoses (e.g., Type 2 DM, on pills since 1995, mild neuropathy, no known retinopathy/nephropathy)
Medications
Includes dose, route and frequency for each medication Includes over the counter and herbal remedies
Allergies Includes nature of adverse reaction
Review of Systems

Most systems are evaluated (e.g. Constitutional, HEENT, Respiratory, Cardiovasc, GI, GU, Neuro, Psych, Endocrine, Musculoskeletal, Hematologic/ Lymph, Skin)
Does not include PMH (ex. Cataracts or heart murmur belong in PMH, not ROS)
Does not repeat information already in HPI
Adequate depth (e.g. GI: no abdominal pain, bloating, nausea, vomiting, melena, hematochezia, change in color, caliber, consistency or frequency of stool)
Social History

Occupation, marital status
Tobacco, EtOH, and substance abuse Functional status, living situation
Family History

State of health of parents, siblings, children
Extended family occurrence of CAD, DM, HTN and cancer
Age at diagnosis of important diseases, especially if premature onset (e.g. CAD in brother age 37, colon cancer in father age 42)
Physical
Examination

Includes areas relevant to the chief complaint (e.g. for patient with cirrhosis includes presence/absence of stigmata of liver disease, for patient with CHF in differential diagnosis includes presence/absence of JVD, crackles, murmur, gallops, liver size, edema, etc)
Does not include assessments/interpretations in PE section (e.g. describes “8x10cm oval area of warm, erythematous skin on medial aspect of left thigh” instead of “cellulitis on medial aspect of left thigh”)
Physical Examination, continued

Includes general description
Includes vital signs (including O2 sats, orthostatics, and pain level when appropriate) Includes skin examination
Includes lymph node survey (not limited to neck nodes only)
Includes thyroid examination
Respiratory includes more than “clear to auscultation”
Cardiovascular includes assessment of neck veins, and distal pulses
Abdominal examination includes measured liver span
Includes rectal exam (or reasonable statement as to why not performed)
Neurologic examination includes mental status, cranial nerves, strength, sensation, cerebellar function and reflexes
Laboratory and Other Studies
Includes lab data appropriate for HPI
Lab data adequately reported (e.g. includes intervals on EKG for patient with syncope)
Problem List

Includes all active medical problems
Includes significant abnormalities in physical examination and laboratory studies Includes health maintenance/screening issues when appropriate
Discussion/
Assessment
And Plans

Includes sentence summarizing key history, PE and laboratory data
Discussion is specific to the patient, not a summary of textbook or review article Adequate differential diagnosis reviewed for major problems
Evaluation/diagnostic strategy proposed (or reviewed if already performed) Management strategy discussed
Reflects an understanding of the pathophysiology of the patient’s illness
Style

Legible
Not laden with spelling or grammatical errors
Uses medical abbreviations appropriately, does not coin own abbreviations