NUR 415 Example of H&P Documentation

Example of H&P Documentation HISTORY: Chief complaint: Fatigue and cough PMH: Mild, intermittent asthma: no current or recent exacerbation Personal/social history: Marital status/personal support system: Single, not currently in a relationship Housing: Dorm of the university Occupation: Full-time student Substance use: Occasional beer or wine after studying Family history: Father: 57, healthy; Mother: 58, hypertension; Siblings: N/A HPI: Marvin Webster is a generally healthy 18-year-old college student who presents with the sudden onset of fever, headache, myalgias, weakness and fatigue and nonproductive cough without wheezing. He reports associated symptoms of fevers, muscle aches, sore throat, tender cervical lymph nodes, right ear pain. He denies known sick contacts. PMH is significant for "mild" asthma, for which he has not needed treatment in the recent past; however, he reports that a single trial of his inhaler was of no benefit for his current symptoms. He is worried about missing school. He was fully immunized in accordance with student-health requirements; however, he did not undergo seasonal flu immunization as recommended and encouraged.