Male and Female History and Physical Examination document the male history and PE as a progress note and you will document the female history and PE as a progress note.
Week 4 Male and Female History and Physical Examination
Male and Female History and Physical Examination Attached Files
- Male & Female Wellness H & PE Assignment.docx (13.363 KB)
Male Wellness History and Physical Examination Assignment
Female Wellness History and Physical Examination Assignment
Value: Two H&P’s equal 20% of total grade
1) Male History and Physical Examination (10%) and
2) Female History and Physical Examination (10%).
Due Date: To be determined at onsite residency
Page Limit: Maximum of 3 single spaced pages for each progress note. Page limit does not include cover page. (No reference page needed, as this is a “progress note.”)
Male and Female History and Physical Examination Instructions
PART 1: THE HISTORY:
1) Review the Chapter’s in Bates and Dain regarding male and female reproductive health.
2) During your onsite residency, you were given the opportunity to observe and
to perform a male and a female genitourinary (GU) examination. For this
assignment, you will submit two progress notes.
3) You will document the male history and PE as a progress note and you will document the female history and PE as a progress note.
4) Begin by documenting the history questions that you would ask a male and then a female patient who present to you for his/her “annual wellness exam.” You will include all of the pertinent sections of the history for this assignment. For the “cc” you may simply write: “I am here for my annual female (or male) exam.” For the history of present illness section, you can simply write that the patient has presented for his/her annual examination and is in good health, with no concerns.
6) You are developing the “questionnaire” that you might use in practice when seeing a patient who presents for his/her “annual wellness examination.” You will not have any patient answers to document because you did not perform the actual history. You will, however, document the questions that you would have asked.
Male and Female History and Physical Examination
7) Use the systematic format that you have been educated to follow. Remember, this is oftentimes the only time a healthy patient will be seen by you; once a year for his/her annual exam. You want to be as thorough as possible when gathering patient information.
Again, the history portion of this assignment is the history that you would have performed.
Part 2 Physical Exam
Male and Female History and Physical Examination Assessment
- Include an appropriate assessment including negative findings documented clearly
- Include your differential with rationales for your selection here.
- Your actual diagnosis with the rationale
Male and Female History and Physical Examination Plan
- Include Pt education with learning needs to be prioritized
- Labs & diagnostics needed
- Follow up plan
- Treatment strategies
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