Patient History and Physical (H&P) Template

References

U.S. National Library of Medicine. (n.d.-b). Arrhythmia | irregular heartbeat. MedlinePlus. https://medlineplus.gov/arrhythmia.html

U.S. National Library of Medicine. (n.d.-h). High blood pressure in adults – hypertension: Medlineplus medical encyclopedia. MedlinePlus. https://medlineplus.gov/ency/article/000468.htm

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Change the common terms found in the history and physical (H&P) into medical terms or abbreviations of a patient who presented to an emergency room with a number of issues. Spell all medical terms or abbreviations and common terms correctly on the provided template.

Introduction
This assessment covers terms related to body systems, structures, and functions. The focus will be on the nervous system. But, included are the digestive system and psychiatry. The nervous system carries messages to and from the brain. The digestive system turns food into energy. Psychiatry is how the brain thinks.

Your resources address diseases and treatments for the nervous and digestive systems, and information on psychiatry.

In the assessment, you will review a history and physical (H&P) report. This is a common document found in acute care settings. You will change the common terms found in the H&P into the correct medical terms.

Instructions
Review the H&P below for a patient who presented in the emergency room with a number of issues. Pay close attention to the history of present illness (HPI), past medical history, medications, allergies, social history, family history, review of systems, physician exam, assessment, and plan. Next, download the Patient History and Physical Template [DOCX] and complete all of the following on the template:

• Select 12 common terms from the H&P that can be changed into a medical term.
• Change the 12 selected common terms into medical terms or abbreviations.
• The first column (right side) of the worksheet should be the common terms found in the H&P below.
• Common and medical terms should include structure/function terms, and body system terms.
• Select 3 common terms from the H&P that relate to a specialized area of medicine such as radiology or surgery (procedural terms).
• Change the 3 selected common terms into the medical term for the radiology or surgical procedure.
• Build your medical terms using word parts.
• Be sure that your common term means the same thing as your medical term. For example: problems breathing is dyspnea (problems = dys, breathing = pnea). Shortness of breath is not dyspnea. Dys does not mean shortness. However, shortness of breath can be abbreviated to SOB
• Be sure to spell the common and medical terms correctly.

Patient H&P

• History of Present Illness:
  • This is a 54-year-old female who presented to the emergency room with a headache in the back of her head and double vision. She also complains of being able to see only from half of her eye. These symptoms began suddenly while she was out walking her dog about 45 minutes ago. A family member brought patient directly to the emergency room for evaluation.
• Past Medical History:
  • High blood pressure.
  • High cholesterol.
  • Irregular, rapid heartbeat.
  • IBS.
  • Cholelithiasis with cholecystectomy.
• Medications:
  • Diovan 80 mg with hydrochlorothiazide 12.5 mg daily.
• Allergies:
  • None.
• Social History:
  • Non-smoker, no alcohol.
• Family History:
  • Both parents and older siblings died from a stroke. Grandparents had extensive colon polyps.
• Review of Systems:
  • She has bilateral vision defects. Denies dizziness, weakness, or numbness. Denies shortness of breath, problems breathing, and chest pain. Denies nausea, vomiting, and blood in stool. No bladder or bowel changes. No edema or skin changes to arms and legs.
• Physician Exam:
  • General: Female patient who is alert.
  • Vital Signs: Stable.
  • Skin: No discoloration, no tissue breakdown.
  • Head, Eyes, Ears, Nose, Throat: Pupils equal, round, and reactive to light; Chest: Clear.
  • Heart: Irregular, rapid rhythm.
  • Abdomen: No guarding, some tenderness related to the IBS.
  • Arms and Legs: No leg swelling.
• Assessment and Plan:
  • Headache in the back of the head with vision changes: Obtain a computed tomography scan and magnetic resonance imaging scan. Depending on test results, an artery repair procedure may need to be considered.
  • High blood pressure: Continue home meds.
  • Irregular, rapid heartbeat: Continue home meds.
    

    Patient History and Physical (H&P) Template

Additional Requirements

• Format: Ensure you complete all columns on the Patient History and Physical Template.
• Scoring Guide: Be sure to review the scoring guide for this assessment so you understand how your faculty member is going to evaluate your work.

Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 2: Use medical terminology and abbreviations related to general structures and functions of the human body.
  • Identify common terms related to general structures and functions of the human body correctly.
  • Change common terms related to general structures and functions of the human body into medical terms or abbreviations correctly.
• Competency 3: Use medical terminology and abbreviations related to body systems.
  • Identify common terms related to body systems correctly.
  • Change common terms related to body systems into medical terms or abbreviations correctly.
• Competency 4: Use medical terminology and abbreviations related to specialized areas of medicine.
  • Identify common terms related to specialized areas of medicine correctly.
  • Change common terms related to specialized areas of medicine into medical terms or abbreviations correctly.
• Competency 6: Spell and pronounce basic medical terms.
  • Spell common and medical terms or abbreviations correctly.