Health History and Physical Assessment Case Study & Worksheet

DescriptionFinal Case Study Presentation Grading Criteria
Case Study # ____________
Good – 4
Satisfactory- 3
Needs Improvement- 2-0
History of Present
Illness/Health is well described
with visual aids. Patient
context, scenario, and reason
for seeking care is clearly
detailed to audience.
History of Present
Illness/Health is well
described. Patient context,
scenario, and reason for
seeking care is clearly
detailed to audience.
History of Present
Illness/Health is well
described. Patient context,
scenario, and reason for
seeking care is stated to
audience.
History of Present
Illness/Health is poorly
communicated. Patient
context, scenario, and reason
for seeking care is not clearly
communicated
Included comprehensive and
specific subjective data of their
Review of Systems on their
patient.
Included basic subjective data
of their Review of Systems
on their patient.
Included minimal
subjective data of their
Review of Systems on their
patient.
Included all SBAR
components.
Included three SBAR
components.
Included objective data and
subjective data. Did not
differentiate the findings
during the Review of Systems
and Physical Assessment
Examination.
Excellent- 5
I.
Total Score: _______/50
Team # __________________
Presentation Content
Introduction
Score:____________
Review of Systems
Score: _________
Included two SBAR
components.
Included one SBAR
component.
Included objective data and
subjective data. Did not
differentiate the findings
during the Review of Systems
and Physical Assessment
Examination.
Included comprehensive and
specific objective data of their
physical assessment and
examination on their patient.
Included basic objective data
of their physical assessment
and examination on their
patient.
Included minimal objective
data of their physical
assessment and
examination on their
patient.
Medications
Team thoroughly
demonstrates patient
education for one medication
listed.
Team adequately
demonstrates patient
education for one
medication listed.
Team minimally
demonstrates patient
education for one
medication listed.
Team inadequately
demonstrates patient
education for one
medication listed.
Pathophysiology
Team thoroughly
demonstrates understanding
Team adequately
demonstrates
understanding of the
Team minimally
demonstrates
understanding of the
Team inadequately
demonstrates understanding
Physical Assessment and
Examination
Score: _________
Final Case Study Presentation Grading Criteria
Health Promotion
Score: _________
References
Score: _________
II.
Delivery
Score: _________
III.
Visual Aids
Score: _________
of the mechanism of health
conditions.
mechanism of health
conditions.
mechanism of health
conditions.
of the mechanism of health
conditions.
Team states 3 areas where
health promotion is needed for
their patient. Provides more
than three specific examples of
how they gave patient
education. Clearly described
how their health promotions fall
in line with the Healthy People
2020 Objectives.
Group states 3 areas where
health promotion is needed
for their patient. Provides
three specific examples of
how they gave patient
education. Described how
their health promotions fall in
line with the Healthy People
2020 Objectives.
Group states 3 areas where
health promotion is needed
for their patient. Provides
three examples of how they
gave patient education.
Described how their health
promotions fall in line with
the Healthy People 2020
Objectives.
Group states 3 areas where
health promotion is needed for
their patient. Provides less
than three examples of how
they gave patient education.
Did not describe or poorly
described how their health
promotions fall in line with the
Healthy People 2020
Objectives.
References are included at the
end of the presentation.
References are all listed in APA
format and can be read by the
audience. Healthy People 2030
is referenced.
References are included at the
end of the presentation.
References are all listed in
APA format and can mostly
be read by the audience.
Healthy People 2030 is
referenced.
References are included at
the end of the presentation
and cited in a specific
format (APA, MLA, etc.).
Healthy People 2030 is
referenced.
No references are included or
references are cited without a
format. Healthy People 2030 is
not referenced.
All members have a clear role
in the presentation. All
members are enthusiastic
speakers and take part in the
presentation. Maintains
appropriate volume and eye
contact with audience.
On-time (20 minutes)
Including Q&A
All photos, designs, transitions,
and animations are aesthetically
incorporated. Words are large
enough for audience to read.
All visual aids enhance the
presentation.
All members speak during
presentation and most are
enthusiastic. Maintains
appropriate volume and eye
contact with audience.
On-time (20 minutes)
Including Q&A
All members speak during
the presentation and
maintain eye contact with
the audience. Words are
clear and enunciated.
On-time (20 minutes)
Including Q&A
Poor or inconsistent eye
contact. Volume of the
speakers are too loud or low.
Presentation is dominated by
one or two speakers. Poor
enthusiasm from the group.
Over-time (> 20 minutes)
Including Q&A
All visual content are
pleasing to the eye and
contributes to the
presentation. White space,
headings, and words are used
appropriately.
Appropriate use of white
space. Visual content is
adequate. Most words are
large enough for audience
to read.
Show some structure. Visual
contents are pixelated,
cluttered, and unrelated to
presentation. Most words are
too small to read.
Final Case Study Presentation Grading Criteria
IV.
Question and
Answer Period
Score: _________
Statements are uniformly
answered with consistent
information. All members of
the group take part in the
question and answer period.
Answers from the group
members show knowledge at a
proficient and professional
level.
Statements are uniformly
answered with consistent
information. Some members
of the group take part in the
question and answer period.
Answers from the group
members show knowledge at
a professional level.
Statements are uniformly
answered with consistent
information. Some
members of the group take
part in the question and
answer period. Answers
from the group members
show basic knowledge of
the content.
Inappropriate use of white
space.
Statements are not uniformly
answered with varying
information. One member of
the group takes part in the
question and answer period.
Answers from the group
members show gaps in
knowledge of the content.
Department of Nursing
Grading Criteria for Complete Health Assessment Case Study Paper
Team
#_____________________________Names:_____________________________________________________________________
_________________Date: __________
Content
Possible Points
1. Biographical Data, Source and Reliability of
Information, Reason for Seeking Care are
complete.
5
2. History of Present Illness is written in paragraph
form.
15
3. Review of Systems (Subjective data)– discuss
history of each system and use abbreviated
format, not complete sentences: general,
psychiatric, skin, hair, nails, lymph nodes, HEENT
(head, eyes, ears, nose, mouth, throat), neck,
blood, breasts, cardiovascular, respiratory, GI,
GU, musculoskeletal, neurologic, endocrine
20
4. Physical Assessment: General Survey, Vital Signs,
Height and Weight, Pain Assessment, BMI
5. Physical Examination (Objective Data)– Vital
signs, general appearance, psychiatric, HEENT,
neck, breasts, lymph nodes, pulmonary,
cardiovascular, skin, nails, abdomen,
genitourinary, pelvic, rectal, extremities,
musculoskeletal, neurological (DTR’s, reflex
grading, cranial nerve evaluation)
10
6. Medications – For each medication the client is
taking fill out a Patient Education Sheet that
includes
• Why/How patient takes the medication
• The 3 most common side effects &
symptom(s) to report
• Address patient medication related
concerns
15
25
Student’s Score
Department of Nursing
Grading Criteria for Complete Health Assessment Case Study Paper
7. Health Promotion: State 3 areas where health
promotion is needed for this patient. Provide
specific examples of how you would educate this
patient. Describe how these health promotion
teachings fall in line with the Healthy People
2030 Objectives.
10
100
TOTAL
Note – Students may use the Complete Health Assessment form on pg.784 in the Jarvis textbook as a guide as a guide for
write-up but using own words as it relates to the case study. References should be cited using proper APA format. Use the
Patient Education Sheet provided for each medication.
Comments:
CASE STUDY I
Mr. James. is a 59-year old black man. He is married, lives with his wife of 33 years, and has 2 grown children. He has
smoked cigarettes since the age of 23, and currently smokes 1 ppd. He drinks beer on the weekends, usually 1 – 2 cans
when watching sports on TV. His past health history includes arthritis and mild chronic heart failure. He is compliant with
his medications and sees his primary care physician regularly for follow up. However, he has not been successful quitting
smoking. He has tried to quit on his own and has never attended any smoking cessation classes.
He is employed as a car salesman and reports that his job is becoming increasingly stressful as he tries to compete with
coworkers who are “younger more energetic”. Over the past 2 – 3 months, Mr. James has experienced increased
indigestion and stomach pain. He has taken OTC antacids with little relief. Two days ago he began to pass black stools,
which caused him to see his primary care provider and led to his admission to the hospital for evaluation.
Admission Diagnoses:

GI bleed

Hx of Heart failure

Arthritis
Meds on admission:

enalapril 5 mg b.i.d

naproxen 500 mg b.i.d.
Admission labs

Hgb – 10.3g/dL (12-18 g/dL)
CASE STUDY I

Platelets – 162 – 109/L (150 – 450 – 109/L)

INR – 1.1 (0.8 – 1.2)

LFTs – all WNL
Admission vital signs: BP 110/66 — T 98.3 — P 92 — R 20 — Ht. 5’11” — Wt. 254#
On admission an IV of normal saline was started and an endoscopy was performed. His medications were stopped
pending further evaluation. Results of the endoscopy with biopsy confirmed the diagnosis of a bleeding duodenal ulcer
without H. pylori. Provided his condition remains stable, he is expecting to be discharged from the hospital.
Discharge Diagnosis




PUD
Anemia 2o GI bleeding ulcer
Osteoarthritis
Heart Failure
Discharge Orders



Omeprazole 20 mg po daily before same meal for 4 weeks
Repeat colonoscopy in 1 month
d/c naproxen
INSTRUCTION
You are the nurse conducting an exam on 12/11 for Mr. James’ next follow up appointment. Include a complete
health history, physical examination, medication education, and three health promotion topics.

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