Submit your order instructions

Get essay writer assigned

Receive your completed paper

History and physical documentation for convulsive syncope

This graduate-level nursing assignment example provides a comprehensive history and physical (H&P) documentation of a 15-year-old male who was followed up for convulsive syncope. The document includes detailed sections on the patient’s medical, family, and social history, showcasing a deep dive into his current health status and background. It explores various aspects of his health, including allergies, past medical history, and family medical history. The sample uses APA style formatting and provides a robust analysis, including differential diagnoses and a care plan, emphasizing the student’s ability to integrate clinical data with academic research.

Octobre 16, 2024

* The sample essays are for browsing purposes only and are not to be submitted as original work to avoid issues with plagiarism.

History and Physical Documentation

Student’s Name

Institutional Affiliation

Course

Professor

Date

History and Physical

Provider: …………………

Patient: 15-year-old male

Date and Time: …………………

Race: …………………

Insurance: …………………

Allergies: No known food, medication, or latex allergies

Historian

Information was obtained from the mother and the patient, who are considered reliable

historians.

Chief Complaint

Follow-up for convulsive syncope and general health check-up.

HPI

The patient is a 15-year-old male presenting for a follow-up visit after being diagnosed

with convulsive syncope by a neurologist. He reports no new episodes since starting clonazepam

PRN. He is generally well, active in basketball, and meets all developmental milestones.

Past Medical History:

- Birth: Full-term, normal delivery, no complications.

- Hospitalization: No past hospitalizations or surgeries were reported.

- Immunizations: Up-to-date on immunizations.

- Screenings: Vision and hearing screening were WNL.

- Medication: Clonazepam PRN for convulsive syncope

Family History

The patient is a 15-year-old male with a family history that is significant for neurological and

cardiovascular conditions.

•Father (48 years old): Alive and well, with a history of hypertension, well-controlled on

medication (Lisinopril). No known history of seizures or syncope. Father works as an

engineer and is physically active.

•Mother (45 years old): Alive and well. History of migraine headaches, which are

managed with over-the-counter medication (Ibuprofen). No history of syncope or seizure

disorders. Mother is a teacher and has no other significant medical history.

•Paternal Grandfather (Deceased at 72): Died of a stroke secondary to uncontrolled

hypertension. History of cardiovascular disease and Type 2 diabetes. No known history of

seizures or other neurological conditions.

•Paternal Grandmother (75 years old): Alive, diagnosed with Type 2 diabetes, currently

managed with Metformin. No history of neurological conditions.

•Maternal Grandfather (Deceased at 68): Died of myocardial infarction. History of

hypertension and hyperlipidemia. No history of seizure disorders.

•Maternal Grandmother (70 years old): Alive, with a history of controlled

hypertension. No history of seizures or syncope.

Fig 1. Shows family history

Social History

The patient is a 10th grade male student whose age is 15 and he lives with both parents

and two siblings in suburbia. The child is developing appropriately for his age and essentially

follows healthy patterns.

TB Exposure

They also reported that they have never had any contact with tuberculosis (TB). The

patient has never visited regions that have high incidence of TB, has no close relative with TB

and has not been in contact with persons suffering from it.

Lead Exposure

The patient has no history of past exposure to lead. He lives in a new house according to

the year that it was built after the year 1980 thus, he does not have to worry about lead-

containing paint or water.

patient

mother

maternal

grandmother

maternal

grandfather

father

paternal

grandmother

paternal

grandfather

ADLs and Habits

•School: Patient is literate, attending school, doing well academically, and playing

basketball. He has below-par academic performance and gets along well with other

children, and he does not have difficulty focusing.

•Diet: He is a moderate eater and sometimes eats fast food. He has no special diet; he has

three meals a day, mostly his mother’s cooking, and has never claimed that he has any

special diet restrictions.

•Elimination: As regards bowel and urinary habits, none are stated.

•Sleep: The patient gets 8-9 hours of sleep at night, has no artifacts that stimulate the brain

in the bedroom, and avoids screen time at night.

•Activity: He is often involved in sports and other physically challenge activities such as

playing, for example, soccer.

•Oral Health: He brushes his teeth at least twice a day, and attends dentist appointments

without having any dental problems.

Safety Risk Assessment/ Protection by Age

•Helmet Use: While biking the patient wears a helmet.

•Seat Belt Use: He always wears a seatbelt when in a car.

•Substance Use: He claims that he does not take tobacco, alcohol or drugs.

•Sexual Activity: He is a virgin and has never been treated for any kind of sexually

transmitted disease.

•Mental Health: Some of the reasons are listed below, along with the patient's response.

The patient says that they have a good attitude, and have had support from friends and

relatives. There is no potential safety hazard, and no concerns were raised about his

behavior.

Growth and Development

The 15-year-old male patient exhibits appropriate growth and development across all

domains. His physical measurements include a height of 5'10" and a weight of 120 lbs, with a

lean BMI of 17.2. He demonstrates age-appropriate gross and fine motor skills through

participation in basketball and daily tasks. Cognitively, he is in Piaget’s formal operational stage,

showing strong problem-solving abilities (Raggi et al., 2023). Verbally, he communicates

effectively with a broad vocabulary. Socially, he interacts positively with peers and adults.

Fig 2. A growth chart showing height and weight relative to age(years).

Piaget’s Stages of Development

The patient is in the Formal Operational Stage of development, as described by Jean

Piaget, which is from the age of 12 years to adulthood. During this stage, there is more

conceptual thinking, and the person can look at issues in a more logical and formalistic way by

posing hypothetical problems (Devinsky et al., 2021).

This can be evidenced by the fact that the patient displayed a reasonable level of

cognitive function appropriate to this stage during the clinical visit when the patient was able to

think abstractly especially while talking about hobbies and what he or she would like to achieve

in the future. From his understanding of concepts in school and expression of thoughts, he has

advanced from the concrete operational stage. He is on age appropriate developmental level for

his age 15, intellectually normal with no learning disability or school dropping out evidence or

dramatic shift from concrete to formal operational level of thinking.

Erickson theory

The 15-year-old male patient can be assessed according to the psychological stage in

Erikson’s theory of psychosocial development, which is the Identity vs Role Confusion phase

that takes place between 12-18 years. This stage is characterized by personal identity, self-

concept and individuality of adolescents (Abeng et al., 2023).

The patient presents high school behaviors like engaging in interests, practicing

basketball, and attaining personal identity concerning peers and families. He gets involved in

various roles and performs various activities in order to come out with an identity.

From a developmental perspective, he appears to be normal for his age. He goes to

school, plays with other children his age and participates in after-school activities hence his

esteem is steady. His positive social support system enhances his progress in this stage and

decreases the possibility of developing role confusion.

ROS

General: No fever, chills, weight loss, or changes in appetite reported. Patient is well developed

and well nourished. Patient is alert and awake. Well kept and dressed appropriately for the

weather. Patient reports feeling well today with no recent illnesses

Eyes: No changes noted in vision, no eye pain, no redness, no discharge

Ears, Nose, and Throat: No hearing loss or tinnitus, no nasal congestion, sinus pain, or sore

throat

Teeth: No cavities or gum issues; routine dental visits

Endocrine: No symptoms of thyroid dysfunction; no heat or cold intolerance, no excessive thirst

or urination

Cardiovascular: No chest pain, palpitations, or syncope, no edema.

Respiratory: No cough, wheezing, or shortness of breath.

GI: Normal appetite; no nausea, vomiting, or diarrhea, bowel movements are regular without

constipation.

GU: No dysuria, hematuria, or urinary frequency.

Hematologic/Lymphatic: No history of easy bruising or bleeding.

Integumentary: No rashes, lesions, no itching or dryness reported.

Neurological: Patient reports no dizziness, no changes in sensation, coordination, or reflexes.

Patient has a history of convulsive syncope; follows up regularly with neurology.

Musculoskeletal: No joint pain or swelling, physically active in sports.

Psychological: No history of depression, anxiety, or mood disorders. Socially active and

engaged with peers; reports good emotional health.

Physical Assessment

Head: Normocephalic, atraumatic with thick hair. No bumps or dryness noted.

Eyes: Conjunctiva clear, pupils equal and reactive to light, extraocular movements are intact.

Ears: External auditory canals clear, tympanic membranes intact. No discharge noted. No pain,

swelling or redness noted.

Nose: Normal mucosa pink. Nostrils equal and no discharge or congestion noted.

Throat: No redness, swelling, or bumps noted. Tonsils are visible. Soft palate intact and normal

shape.

Cardiovascular: S1 and S2 noted. Strong heart sounds auscultated. No murmur, or gallops

noted.

Respiratory: Lung sounds clear bilaterally, symmetrical chest expansion, no wheezing or

crackles.

Gastrointestinal: Abdomen soft, non-tender, non-distended. Bowel sounds normal.

Integumentary: Skin warm, dry, and intact with no lesions, rashes, or abnormalities noted.

Nails: Cap refill less than 3 seconds.

Neck: No rash or darkening around the neck. Lymph nodes palpated and no swelling noted. No

deviation noted.

Neurological: Patient is alert, attentive, and oriented to person, place, and time. Cranial nerves

II-XII intact. Sensation intact in all extremities.

Physiological: No edema or trauma.

Motor: Full range of motion in all extremities. No swelling, deformities, or tenderness noted.

Vital signs:

Blood Pressure: 110/65 mmHg (Normal)

Heart Rate: 70 beats per minute (bpm) (Normal)

Temperature: 98°F (36.7°C) (Normal)

Oxygen Saturation (SpO₂): 100% (Normal)

Height: 5'10" (178 cm) (Normal for age)

Weight: 120 lbs (54.4 kg) (Normal for age)

Body Mass Index (BMI): 17.2 (Calculated as weight in kg/height in m², normal)

Differential Diagnosis/ Possible

1. Convulsive Syncope (ICD-10: R55)

- Rationale: This diagnosis can be considered related, particularly to the history of convulsive

syncope, which the patient has (Norris et al., 2022). convulsive syncope mimics seizures, and

involves sudden fainting and muscular twitching.

2. Epilepsy (ICD-10: G40.9)

- Rationale: Even if the patient had convulsive syncope this does not completely rule out the

possibility of the presence of other related diseases such as epilepsy.

3. Vasovagal Syncope (ICD-10: R55)

- Rationale: Vasovagal syncope is a very common form of syncope in adolescents, and one can

experience what looks like a seizure during a vasovagal episode (Norris et al., 2022). The

common causes include stress, dehydration or staying for a long time on the feet. Given patient’s

age, this diagnosis should be considered where there are other symptoms, such as dizziness or

chest pain, before the episodes.

4. Orthostatic Hypotension (ICD-10: I95.1)

- Rationale: Orthostatic hypotension leads to Syncope and is most prevalent in the adolescent

age. Reduced blood pressure and dizziness that can cause fainting are common in this condition,

normally resulting from blood pressure dropping greatly on standing (Perucca et al., 2020).

5. Cardiac Arrhythmia (ICD-10: I49.9)

- Rationale: Cardiac arrhythmias often manifest with syncope and may be accompanied by

regular abnormal heart rhythms. Since syncope can arise from a temporary ischemia of the brain,

the cardiac status of the patient must be assessed, especially, if the patient complains of

palpitations or has a family history of cardiac problems.

Primary Diagnosis: Convulsive Syncope is coded as R55 in the ICD–10

a) Pathophysiology: Convulsive syncope is brief fainting occasioned by a momentaneous

circulatory failure of the brain, precipitated by stress, dehydration or postural changes. This leads

to a small amount of temporary neurological dysfunction and leads to muscular spasms

mimicking epilepsy (Sheibani et al., 2023).

b) Rationale: Due to the previous past history of seizure-like episodes associated with

syncope, but normal neurological examinations, this ruled out other causes for syncope, such as

epilepsy or cardiac syncope (Kanner & Bicchi, 2022).

c) Diagnostic Testing: The EEG is useful in distinguishing between seizure disorders and

syncope While Cardiac monitoring, such as holter monitor, may be done to rule out arrhythmias.

d) Medications: Clonazepam is ordered PRN for control of possible seizures.

e) Non-Pharmacological Treatment: correctly is counseling regarding adequate fluid intake,

no exposure to triggers relevant to the cause, and teaching on safe practices during syncope.

f) Patient and Family Teaching: Provide the patient and family information on when

syncope is likely to occur, what to do during a syncope episode and when to seek medical help.

Engage the patient in talking about ways through which one can avoid falling sick and having

more episodes.

Assessment and Plan

1. Convulsive Syncope

- Medication: Clonazepam for restless leg syndrome 0.5 mg orally for as-needed

- Route: Oral

- Frequency: As needed for seizure, such as like episodes

- Duration: Duration – episodes occur. Review at 3 months.

- Rationale: Clonazepam is well used in seizure treatment and gives a patient a very quick

relief of anxiety, which often occurs with syncope. It has the role of minimizing the likelihood

and intensity of possible seizures (Alwi et al., 2023).

2. Psychosocial Support

- Recommendation: Being referred to a psychologist or counselor

- Rationale: According to anxiety or stress related to the condition of the patient, coping

strategies may be asked to help lessen the incidences of syncope (Samsanovich, 2021).

3. Lifestyle Modifications

- Recommendation: Take plenty of water and try not to stand for a long time or get dehydrated.

- Rationale: It can be postulated that a wet cough increases the chances of syncope by reducing

cerebral perfusion if adequate hydrations is not maintained.

4. Follow-Up:

- Recommendation: Refer patient back to this clinic in three months to review the progress and

effects of medications on the condition.

- Rationale: The treatment response can be assessed through constant follow-up, and the

therapy can be altered correspondingly.

References

Abeng, F. E., Ita, B. I., Anadebe, V. C., Chukwuike, V. I., Etiowo, K. M., Nkom, P. Y., Ekerenam,

O. O., Iroha, N. B., & Ikot, I. J. (2023). Multidimensional insight into the corrosion

mitigation of clonazepam drug molecule on mild steel in chloride environment: Empirical

and computer simulation explorations. Results in Engineering, 17, 100924. https://

doi.org/10.1016/j.rineng.2023.100924

Alwi, R. S., Rojas, A., Esfandiari, N., Sajadian, S. A., Ardestani, N. S., & Jouyban, A. (2023).

Experimental study and thermodynamic modeling of clonazepam solubility in

supercritical carbon dioxide. Fluid Phase Equilibria, 574, 113880. https://doi.org/

10.1016/j.fluid.2023.113880

Devinsky, O., King, L., Schwartz, D., Conway, E., & Price, D. (2021). Effect of fenfluramine on

convulsive seizures in CDKL5 deficiency disorder. Epilepsia, 62(7), e98–e102. https://

doi.org/10.1111/epi.16923

Kanner, A. M., & Bicchi, M. M. (2022). Antiseizure Medications for Adults With Epilepsy: A

Review. JAMA, 327(13), 1269–1281. https://doi.org/10.1001/jama.2022.3880

Norris, S. A., Frongillo, E. A., Black, M. M., Dong, Y., Fall, C., Lampl, M., Liese, A. D., Naguib,

M., Prentice, A., Rochat, T., Stephensen, C. B., Tinago, C. B., Ward, K. A., Wrottesley, S.

V., & Patton, G. C. (2022). Nutrition in adolescent growth and development. The Lancet,

399(10320), 172–184. https://doi.org/10.1016/S0140-6736(21)01590-7

Perucca, P., Bahlo, M., & Berkovic, S. F. (2020). The Genetics of Epilepsy. Annual Review of

Genomics and Human Genetics, 21(Volume 21, 2020), 205–230. https://doi.org/10.1146/

annurev-genom-120219-074937

Raggi, A., Mogavero, M. P., DelRosso, L. M., & Ferri, R. (2023). Clonazepam for the

management of sleep disorders. Neurological Sciences, 44(1), 115–128. https://doi.org/

10.1007/s10072-022-06397-x

Samsanovich, A. (2021). THEORY AND DIVERSITY: A DESCRIPTIVE STUDY OF

ERIKSON’S PSYCHOSOCIAL DEVELOPMENT STAGES. Electronic Theses,

Projects, and Dissertations. https://scholarworks.lib.csusb.edu/etd/1230

Sheibani, M., Shayan, M., Khalilzadeh, M., Ghasemi, M., & Dehpour, A. R. (2023). Orexin

receptor antagonists in the pathophysiology and treatment of sleep disorders and epilepsy.

Neuropeptides, 99, 102335. https://doi.org/10.1016/j.npep.2023.102335

Octobre 16, 2024

24/7 custom essay writing by real academic writers

WPH

Academic level:

Graduate

Type of paper:

Assignment

Discipline:

Nursing

Citation:

APA

Pages:

4 (1100 words)