, Advanced Health Assessment
Instructions: Type patient encounter information directly into each box of the template. Students
should avoid the use of the following terms: “WNL”/”Normal”, etc and should document systems with
specificity and accuracy. Students are also expected to incorporate any feedback faculty have provided
on previous cases into each subsequent assignment.
CC: 49-year-old female Ms. Barnes is a 49-year-old female with chest pain and
dyspnea that started 2 weeks ago during a ski run activity
Chief complaint is a short 1-2
statement or word phrase from patient
in the cold. She reports that the chest pain radiates to the
and should be listed in “quotes” left arm and has a squeezing quality to it. The pain is
exacerbated by fast walking in the cold and relieved by
“Exertional mid-chest pain that resting.
radiates to left arm with a
squeezing quality” Onset: Chest pain 2 week ago during a cross-country ski
run
HPI: pertinent s/s; +/- ROS/prior
episodes/recent travel/ill contacts
PMHx child/adult illness/hospitalizations/immunizations History of hypertension
and high cholesterol
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller MREXAMS. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.99. You're not tied to anything after your purchase.