- HIM FPX 4610 Assessment 2 History and Physical (H&P): The Nervous System.
Patient History and Physical (H&P)
Number |
Common Term |
Medical Term or Abbreviation |
Example 1 |
The big bone at the top of the leg |
Femur |
Example 2 |
Cutting off or removing a muscle |
Tendonectomy |
Example 3 |
Ears, nose, throat |
ENT |
1. |
The backside of the head |
Occipital bone (Germann & Kashyap, 2020). |
2. |
Seeing double. |
Diplopia (Jain, 2022). |
3. |
Only able to see out of one eye |
Hemianopsia (Ruddy & Cardenas, 2021). |
4. |
Too much blood pressure. |
Hypertension (Gabb, 2020). |
5. |
Lots of fat. |
Hypercholesterolemia (Ahangari et al., 2018). |
6. |
Rapid and irregular beating. |
Atrial fibrillation (Michaud & Stevenson, 2021). |
7. |
Feeling weak, dizzy, or numb. |
Presyncope (Hockin et al., 2022). |
8. |
Being unable to breathe |
Dyspnea (Deepa Rawat et al., 2019). |
9. |
Pain in the chest |
Angina pectoris (Ford & Berry, 2020). |
10. |
A stool with blood in it |
Melena (Iwama et al., 2021). |
11. |
No changes in the bladder or bowels |
Urinary and fecal incontinence intact (Knowles et al., 2022). |
12. |
swollen arms and legs or changes in the skin |
Peripheral edema (Besharat et al., 2021). |
13. |
Move your eyes |
Ocular motility (Conti et al., 2021). |
14. |
Headache |
Cephalgia (Baroness & Baker, 2020). |
15. |
Not a smoker and no drinking. |
Abstinence from nicotine and ethanol (Roehrs & Roth, 2019). |
Read more about our sample HIM FPX 4610 Assessment 1 Progress Note- The Skin for complete information about this class.
References
Ahangari, N., Ghayour Mobarhan, M., Sahebkar, A., & Pasdar, A. (2018). Molecular aspects of hypercholesterolemia treatment: Current perspectives and hopes. Annals of Medicine, 50(4), 303–311.
https://doi.org/10.1080/07853890.2018.1457795
Baraness, L., & Baker, A. M. (2020). Acute Headache. PubMed; Statpearls publishing.
https://www.ncbi.nlm.nih.gov/books/NBK554510/
Besharat, S., Grol-Prokopczyk, H., Gao, S., Feng, C., Akwaa, F., & Gewandter, J. S. (2021). Peripheral edema: A common and persistent health problem for older Americans. PLOS ONE, 16(12), e0260742.
HIM FPX 4610 Assessment 2 History and Physical (H&P): The Nervous System
https://doi.org/10.1371/journal.pone.0260742
Conti, M. L. D., Osaki, M. H., Sant’Anna, A. E., & Osaki, T. H. (2021). Orbitopalpebral and ocular sarcoidosis: what does the ophthalmologist need to know. British Journal of Ophthalmology, 106(2), 156–164.
https://doi.org/10.1136/bjophthalmol-2020-317423
Deepa Rawat, Hajira Basit, & Sandeep Sharma. (2019, December 13). Dyspnea. Nih.gov; Statpearls publishing.
https://www.ncbi.nlm.nih.gov/books/NBK499965/
Ford, T. J., & Berry, C. (2020). Angina: Contemporary diagnosis and management. Heart, 106(5), 387–398.
https://doi.org/10.1136/heartjnl-2018-314661
Gabb, G. (2020). What is hypertension? Www.nps.org.au, 43(4).
https://doi.org/10.18773/austprescr.2020.025
Germann, A. M., & Kashyap, V. (2020). Anatomy, Head and Neck, Occipital Bone, Artery, Vein, and Nerve. In PubMed. Statpearls publishing.
https://www.ncbi.nlm.nih.gov/books/NBK541093/
Hockin, B. C. D., Heeney, N. D., Whitehurst, D. G. T., & Claydon, V. E. (2022). Evaluating the impact of orthostatic syncope and presyncope on quality of life: A systematic review and meta-analysis. Frontiers in Cardiovascular Medicine, 9.
https://doi.org/10.3389/fcvm.2022.834879
Iwama, I., Yoshida, M., Hara, T., & Nambu, R. (2021). Causes of melena and effective examination strategies in children. Frontiers in Pediatrics, 9, 780356.
https://doi.org/10.3389/fped.2021.780356
Jain, S. (2022). Diplopia: Diagnosis and management. Clinical Medicine, 22(2), 104–106.
https://doi.org/10.7861/clinmed.2022-0045
Knowles, C. H., Dinning, P., Scott, S. M., Swash, M., & de Wachter, S. (2022). New concepts in the pathophysiology of fecal incontinence. Annals of Laparoscopic and Endoscopic Surgery, 7, 15–15.
https://doi.org/10.21037/ales-2022-02
Michaud, G. F., & Stevenson, W. G. (2021). Atrial fibrillation. New England Journal of Medicine, 384(4), 353–361.
https://doi.org/10.1056/nejmcp2023658
Roehrs, T., & Roth, T. (2019). State-altering actions of ethanol, caffeine, and nicotine. Handbook of Behavioral State Control, 421–432.
https://doi.org/10.1201/9780429114373-26
Ruddy, J., & Cardenas, A. C. (2021). Hemianopsia. PubMed; Statpearls publishing.