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.
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History and Physical Documentation
Student’s Name
Institutional Affiliation
Course
Professor
Date
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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
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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.
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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
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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
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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
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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
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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.
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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:
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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.
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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.
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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.
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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.
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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
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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
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Academic level:
Graduate
Type of paper:
Assignment
Discipline:
Nursing
Citation:
APA
Pages:
4 (1100 words)
* The sample essays are for browsing purposes only and are not to be submitted as original work to avoid issues with plagiarism.
