Instruction
I need a paper written for physical assesment (PA).
GUIDELINES FOR WRITTEN PHYSICAL EVALUATION PAPERS
ADULT EVALUATION
Patient Identification
Age/DOB; Race; Sex; Religion; Occupation
Past Medical History (PMH)- (5 POINTS)
Illnesses; Surgeries/Procedures; Childhood Illnesses; Trauma; Most Recent Physical Examination; LMP
Medications (5 POINTS)
Prescription and OTC dose and frequency
Allergies (2 POINTS)
Medication, Food and Environmental clarify what kind of reaction
Social History (3 POINT)
Tobacco; Alcohol; Caffeine; Recreational Drug Use
Immunizations and Travel (1 POINT)
Family History (FHx) (4 POINTS)
Marital Status; Parents (living, dead, cause of death); family illnesses
Review of Systems: (this is told by the patient during the interview) (15 POINTS)
General; Head, Ears, Eyes, Nose, Throat; Pulmonary; Cardiac; Gastrointestinal; Genitourinary; Musculoskeletal; Vascular; Endocrine; Blood; Integumentary; Psychological
Physical Examination: (this is what the examiner observes) (15 POINTS)
General Appearance; VS; HEENT; Neck; Lymph Nodes; Breast; Respiratory/Thorax; Cardiac; Abdomen; GU (not required for this course- write EXAM DEFERRED); Rectal(not required for this course-write EXAM DEFERRED); Vascular/Pulse; Musculoskeletal; Neurological (including cranial nerves I-XII, Motor, Coordination, Sensory, Reflexes)
i also uploaded two example papers. just make up the information but also make sure it all makes sense. his illnesses match his medications and everything else.