Explore 1+ Powerpoint Assignment Help Solutions


Question Number: 122

Question descriptionTitle: Complete Health History and Physical Assessment Write-Up Power Point PresentationI’ve done the complete health history and physical assessment on the patient already, do not change my information, but you can correct and add to the narrative for me please to make it more professional.I need you to put it into power point slides for me.Use this patient and create a professional Microsoft PowerPoint presentation with narrative slides.Completing the PowerPoint presentation with narrative slides:The health history and physical assessment presentation will utilize the detailed health history and physical assessment you completed.You are to develop a professional PowerPoint presentation with narrative slides that covers the complete health history and physical assessment.You can use the power point sample that I sent to you as an example but I want a different PowerPoint design presentation.Keep in mind that this is a professional presentation.As you are completing the PowerPoint presentation you will need to add more narrative to the slides for me please.The narrative should be added under each slide in the PowerPoint presentation.FYI This is the rubric Grading Criteria, make sure you cover every single point pleaseDeveloped a professional PowerPoint that covers all major topics in the Health History and Physical Assessment Form.Include narrative for each slide (at bottom of slide) of the presentation.Presented the Health History and Physical Assessment in a professional manner using correct medical terminology.Lead discussion with appropriate answers and questions to presentation.Used correct spelling, grammar, and professional vocabulary. Cited all sources using the correct APA style. References cannot be any older than 5 yearsThis is the patient’s informationName: V.A Date: 07/12/2017 Time: 11:00 AMAge: 22 Sex: FemaleSUBJECTIVEChief Complaint: 22 years old female complains of ”Memory lapse, confusion, Headache , disorientation, unsteady at time and dizziness, ringing in ears subsequent to head injury 3 weeks and a couple of days ago and requesting for referral to go to a neurologist”History Of Present Illness: Female patient reported that she had head injury on 7/4/2017 due fall and hit the back of the head Patient reported to have memory lapse, confusion, Headache , disorientation, unsteady at time and dizziness, ringing in ears subsequent to head injury.Medications: Meclizine for dizziness 25mg PO 3 times a dayPrevious Medical History: Head injury 07/4/2017due to fallPrevious Surgical History: Wisdom teeth extractionAllergies: Patient denies has no known medical, environmental or food allergies.Medication Intolerances: NoneChronic Illnesses: MusculoskeletalIndicates having chronic pain in the lower back, hypotrophy, numbness in right arms radiating down into hands, fingers do to MVA, no other muscles, joint pain or swelling, no parenthesis or any numbness and fracture L4-5 2* MVA at age 18Major traumas: patient denies chronic illness and chronic illnessHospitalizations/Surgeries Hospitalization only 07/4/2014 and when has the motor vehicle accident 3 years agoFamily HistoryMaternal: Have CAD and HTNPaternal: Healthy2 brothers alive and wellGrand-parents on both sides diagnose to CVA, HTN, open heart surgery, lung cancerPatient denies family and sibling diagnose with psychiatric illness, kidney disease, tuberculosis, neither diabetes mellitus nor kidney disease.Social HistorySingle, female currently leaving alone with 19 month old son, works as a manager at Tijuana flat restaurant .She is a high school graduate student. She is occasionally drinking alcohol. She reports that she smokes 1 pack of cigaretteNutrition History Mostly eating healthy.Review of SystemGeneralNo weight change, no change in strength. Patient denies fatigue, fever, chills, night sweats. CardiovascularDenies Chest pain, palpitations, edema, history of syncope nor orthopneaSkinBruising on arm due to rough sex as per patient stated, no rashes, bleeding, lesions, abnormal pigmentation or skin discolorations,RespiratoryNo Cough no wheezing, no hemoptysis, no dyspnea, no history of upper and lower respiratory diseaseHead: Headache, dizziness, vertigo, head injury on 7/4/2017 due to fall, hitting back of the head.EyesNormal vision, no diplopia, no tearing nor pain, no blurring.GastrointestinalNo abdominal pain, skin is normal, no distention on inspection, no bowel pattern change, no tenderness, no mass, it is soft when palpate, bowel sound present on all four quadrants when auscultate, no sign of emesis, melena, no change in appetite.EarsShe indicates of feeling ringing in the ears, Tinnitus, no change in hearing, no bleeding, no ear pain, hearing loss no dischargeGenitourinaryGynecological . She indicates have the pap done last yearNo urinary urgency, no dysuria, no frequency, no burning, no change in color of urine, no vaginal discharge no contraception, sexual active with one partner,, no sign of Sexual Transmitted Diseases noted nor reported, no change in menses, no dysmennorya, no pelvic pain, no mammogram , but perform self-breast exam every month after her monthly menstrual period and had 1 pregnancy and one child alive and leaving well.Nose no epistaxis, no obstruction nor dischargeMouth no dental bleeding, no cavitiesThroat no complain of pain, no lesion, uvula are raise and fall, no lesion noted.Neck No stiffness, no pain, no tenderness, massesMusculoskeletalIndicates having chronic pain in the lower back, hypotrophic, numbness in right arms radiating down into hands, fingers do to MVA, no other mucles, joint pain or swelling, no paresthesia or any numbness and fracture L4-5 2* MVA at age 18BreastNo lumps, no tenderness, no swelling, no skin discolorationNeurologicalChanges in mentation, ataxia at times, no sweat no syncope, no seizures, no transient paralysis, no weakness, paresthesias, black out or spells.Heme No sign of skin bruising noted and able to tolerate normal environment temperatureLymph No sign of swollen lymph node notedEndorineNo sign of polydipsia, polyphagia, no polyuria or tachycardia reportedPsychiatricPatient reported changes in sleep habits, no depressive symptoms, no changes in though condition, denies any history of suicidal ideation thoughtOBJECTIVEWeight 140 lbs BMI 23.30 Temp 97.3 F BP 119/70 mmhgHeight 65 inPain Scale 4 on 0-10 Pulse 73 bpm Resp 18 bpmO2 Saturation 97% at room airGeneral Appearance: Alert and oriented healthy adult female appears well and no apparent acute distress.Skin is normal color, write warm, dry, clean no rashes or lesions noted, red bruises observed on right upper arm. Patient stated “It happened is from having rough sex”.HEENTHead: is normocephalic, atraumatic and without lesions; scalp is moist, hair evenly distributed.Eyes: Vision is normal, pupil are equal and reactive to light, non inicteric sclerae.Ears: Tinitus No lesions, no tenderness fluid noted at the ear canals. It looks patent. Bilateral ears tympanics membranes appear normal without sign of infectionNose: is clear, bilateral nostril is symmetrical, no swollen of turbinates, sinuses non tender to palpation, hair is evenly distributed, nasal mucosa pink and moist,Neck: Supple. Patient able to move neck without difficulty, no pain, tenderness, mass, lumps, swollen gland, carotid pulse present, no sign of trachea deviation noted , no jugular vein distention or bruit.Oral mucosa pink and moist, no sign of swollen, bleeding gum notedChest: Symmetric, no chest wall tenderness.Breast no mass, no skin changes, no tenderness, no skin changes, no galactorrheaPharynx is nonerythematous and without exudate. Teeth are in good repair.Cardiovascular S1, S2 normal with regular rate and rhythm. no S3, no S4 sounds, no murmurs. Capillary refill is less than 2 seconds. Pulses 3+ throughout. No edema noted.RespiratoryBilateral patient chest observe symmetrical, she is breathing normally, respiration is even regular and non- labored, lung sound are clear bilateral on all lung , no history of lung diseases reported.Gastrointestinal Patient abdominal skin is warm to touch, soft, non- distended, no guarding, no tenderness to palpation on all quadrants, bowel sound present on all four quadrants on auscultation. Last bowel movement 7/12/2017Breast is bilateral symmetrical, skin is warm to touch with normal color and appearance, no sign of mass , tenderness, no nipple discharge noted.Genitourinary: and rectal exam deferred, but bladder is non-distended up on palpation and inspection.GYN G2P1A1-LMP 6/24/2017 regular. Last Pap done in 09/1/2016 normal resultBack: Patient back shows no sign of spinal tenderness, no spasm, no sign of scoliosis noted and complain of pain voice. Patient was able to bend down and touch her toes and bend laterally touching her ankle without difficulty.Musculoskeletal Hypertrophic to right upper extremity noted, no deformity, no edema, no tenderness, no complain of pain no effusion, noted. Bilateral brachial, radial, femoral, posterior tibialis and anterior tibialis pulses present. Patient was able to perform active range of motion of bilateral upper and lower extremities without difficultiesNeurological: Patient is awake, alert and oriented.Cranial nerves unremarkable, patient’s gait is normal, speech is clear, sensory is normal to light touch and pin prick, balance is normal when patient standing, walking and bending inside of the office. Bilateral upper extremities power and tone are unequal.Sensory normal to light touch and pin prickPsychiatricPatient awake, alert, oriented and verbally responsive, wearing a clean blue jean short with a write long sleeve T-Shirt, she has a white tennis shoes in her feet, speaks with normal voice and able to keep a normal conversation, keep eye contact, maintain good posture during examination timeLab TestsUrine culture and sensitivity, CBC, CMP ,Lipid panel, HbA1C, TSH, T4, Vit D. pendingSpecial Tests: Weber test to check for earing lost. NormalDiagnosisDifferential Diagnoseso 1-Hypotentiono 2- dehydration (ICD-10 )No active chronic diagnosisAcute diagnosisDiagnosis: Headache (ICD-10 code784.0),Dizziness (ICD-10 780.4)Vaginitis( 616.11)Ringing in bilateral ears (388.30)PlanTherapeuticso Plan: Refer patient to neurologist Labs: CBC, CMP, Lipid panel, HbA1C, TSH, T4, UA, and Vit D. Medication: Meclizine 25mg po TID as needed diagnosis diziness NY statin ointment per vagina topical bid #1 tube dispensed. Diflucan 150 mg PO x1 dose, repeat in one week #2. Diagnosis Vaginitis Fallow up in 2 weeks after labs result and call the office for any concerns. Education: To eat low fat diet, low carb, low salt, exercise, no smoking, no drugs, no drinking, keep environment safe, helmet, wash your hands before and after eat, take medications, finish to use the restroom and so on Non-medication treatments: Educated patient to drink plenty of water, cranberry juice to help with infection.Evaluation of patient encounter. Patient verbalized she will apply and the instructions that I gave her

Ans:You can contact with our chat expert in order to get your answer



Students can't be wrong