| Course | NURS 3025 Health Assessment |
|---|---|
| Week | Week 2 |
| Paper type | Health history |
| Length | About 630 words, 5 pages |
| Format | APA 7 student paper |
| School | Walden University |
| Program | Bachelor of Science in Nursing (BSN) |
| Updated | October 2026 |
Free sample paper for NURS 3025 Week 2
Health History: A 34-Year-Old Man With Three Weeks of Intermittent Headaches, Reported Data Only
Student Name
College of Nursing, Walden University
NURS 3025: Health Assessment
Instructor Name
Month Day, Year
Health History: A 34-Year-Old Man With Three Weeks of Intermittent Headaches, Reported Data Only
Identifying Data and Source
A composite 34-year-old man, a software developer, seen in a walk-in clinic. Source: the patient, who appears a reliable historian and answers questions in detail. All information below is as reported by the patient. Naming the source and its reliability at the top of a record is part of documenting in a way others can trust and use (Blair & Smith, 2012).
Chief Concern
"I've been getting headaches on and off for about three weeks."
History of Present Illness
Each headache feature below is recorded under its own label, in the order most history texts teach (Bickley et al., 2021).
Onset: began about 3 weeks ago, gradually, with no identifiable event. Location: both temples and the forehead, "like a band." Duration: each headache lasts 2 to 4 hours. Character: pressing or tight, not throbbing. Aggravating factors: long hours at the computer, skipped meals. Relieving factors: ibuprofen 400 mg, which he reports helps within an hour; lying down in a quiet room. Timing: usually starts in the afternoon at work; 4 to 5 days a week; none on weekends so far. Severity: 4 to 5 on a 0 to 10 scale; has not stopped him from working.
Associated symptoms: reports mild neck stiffness at the end of the day. Pertinent negatives: denies nausea, vomiting, sensitivity to light or sound, visual changes, weakness, numbness, fever, and headache waking him from sleep. Denies any head injury. Denies that this is the worst headache of his life or that any headache began suddenly at full intensity. Reports no previous headaches like these. These negatives are recorded because features such as sudden onset, neurological symptoms, fever, and a new pattern after age 50 are among the red flags that point toward a secondary cause (Do et al., 2019).
Past Health History
Medical: no chronic conditions. Surgical: appendectomy at age 19. Hospitalizations: for appendectomy only. Medications: ibuprofen 400 mg as needed, now taken 4 to 5 days a week for 3 weeks; no prescription medications; no supplements. Allergies: no known drug allergies. Immunizations: reports receiving a tetanus booster "a few years ago"; unsure of influenza vaccination this season. Screening: reports last eye examination "in college."
Family History
Mother, 61: hypertension, migraine since her 20s. Father, 63: type 2 diabetes. Sister, 30: healthy. No known family history of brain aneurysm, stroke before age 50, or brain tumor.
Social History
Lives with his partner. Started a new job 5 weeks ago with longer hours, working 10 to 11 hours a day at a computer. Reports drinking 4 to 5 cups of coffee a day, up from 2 before the new job. Drinks alcohol 2 to 3 times a week, 1 to 2 beers. Denies tobacco and drug use. Reports sleeping 6 hours a night on work nights. Exercise: stopped going to the gym since starting the new job.
Review of Systems
General: reports fatigue in the evenings; denies fever, chills, or weight change. Skin: denies rashes or lesions. Head: headaches as above; denies head injury. Eyes: reports eye strain at the end of the workday; denies blurred or double vision. Ears: denies hearing loss or ringing. Nose and sinuses: denies congestion or facial pain. Mouth and throat: denies jaw pain or teeth grinding that he is aware of. Neck: reports stiffness at the end of the day; denies lumps. Respiratory: denies cough or shortness of breath. Cardiovascular: denies chest pain or palpitations. Gastrointestinal: denies nausea, abdominal pain, or any bowel change. Genitourinary: denies urinary symptoms. Musculoskeletal: reports neck and upper back tightness. Neurological: denies weakness, numbness, dizziness, fainting, or seizures. Psychiatric: reports feeling "stressed" about the new job; denies low mood. Endocrine: denies heat or cold intolerance or excessive thirst. Hematologic: denies easy bruising.
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160-168. https://doi.org/10.5172/conu.2012.41.2.160
Do, T. P., Remmers, A., Schytz, H. W., Schankin, C., Nelson, S. E., Obermann, M., Hansen, J. M., Sinclair, A. J., Gantenbein, A. R., & Schoonman, G. G. (2019). Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology, 92(3), 134-144. https://doi.org/10.1212/WNL.0000000000006697
The Walden NURS 3025 Week 2 instructions
NURS 3025 Week 2 centers on the interview and the full history it yields. You name the source and reliability, record the chief concern in the patient's words, develop the present illness with a mnemonic such as OLDCARTS, and complete past, family and social histories and a review of systems. Faculty check sequence first and then completeness. Cite the course text in APA 7. Only reported data belong in this assignment. Pertinent negatives should be written out, since they show what was asked. A composite patient, or a real one stripped of identifiers, is acceptable. NURS 3025 faculty want the source and reliability stated in the first lines. Quote him for the chief concern.
How this NURS 3025 Week 2 example is built
About four pages of prose under conventional headings. Identifying data and source of history come first, including a note that the patient gave the history and was judged reliable. His chief concern is quoted exactly as he said it. The history of present illness runs as a structured narrative that follows the OLDCARTS mnemonic letter by letter, so each attribute of the headache has a sentence. Medications are listed with the patient's reported use, allergies with the reaction named. Family history appears as a short three-generation summary. The review of systems closes the document, one line per system, with pertinent negatives written as statements such as 'denies visual changes' rather than left blank.
NURS 3025 Week 2 rubric: what earns full marks
Health history rubrics usually reward sequence, completeness and the separation of reported from observed data. Sequence is checked first because a grader expects the standard order and notices the moment it breaks. Completeness lives mostly in the present illness and the review of systems, and a symptom analysis that skips severity or timing loses more than its size suggests, because those attributes decide how the complaint would be read by the next clinician. The review of systems is where the quiet deductions pile up: a list that stops once the obvious systems are covered, or negatives implied by absence. Language carries its own share, since phrasing such as 'patient complains of' is often marked down in favor of neutral verbs. Any objective finding slipping into the document is scored as a structural error.
NURS 3025 Week 2 help from the desk
Health histories lose points when sections appear out of order, which makes the grader hunt. Follow the standard sequence. Another common gap is skipping pertinent negatives, leaving the reader unsure which questions were put. Write them out, such as denies fever or neck stiffness. Writers also slip examination findings into the history. Keep this assignment to reported data. Avoid summarizing the chief concern in clinical words; quote the patient. Use OLDCARTS or a similar mnemonic fully. Include medications, allergies and substance use. Close the review of systems with the systems relevant to headache covered in detail. Writers also forget screen time, sleep and caffeine, which matter for headaches. Ask about each.
Get a NURS 3025 Week 2 example written to your instructions
Share the Week 2 prompt and rubric, along with the chief concern your scenario or simulated patient presents, and the health history returns written around that complaint in standard order, review of systems complete. If your section uses a template, attach it and the headings will match. One free first sample per person, delivered in 24-48 hours.
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NURS 3025 Week 2 questions, answered
How long should a health history run?
Length follows the prompt, and this example runs about four pages because the review of systems is written out in full. Sections that cap the length usually still expect every heading present, which means shorter entries rather than fewer ones. A history trimmed by dropping the social or family section to fit a limit tends to lose more than one written tightly across all of them.
Can the history be based on a patient I cared for?
The sample itself never is. Its patient is invented, a composite whose headache history was put together for teaching, and nothing in it traces to a chart or a shift. When your prompt asks for an interview you conducted, that interview and its consent are yours alone, and the example is there only to show the order the finished history takes.
Why are pertinent negatives written out instead of skipped?
Because a missing line is ambiguous and a written negative is not. 'Denies visual changes' tells the next reader the question was asked and answered, while silence could mean either that nothing was wrong or that nobody checked. For a headache complaint, the negatives that bear on the concern carry as much documentary weight as the positives, and rubrics in this course typically count them.
Where can I find a free NURS 3025 Week 2 sample paper?
The headache health history is reproduced here with the source named, the chief concern in his words, OLDCARTS, the full history and the review of systems.
Which mnemonic builds the present illness in NURS 3025 Week 2?
OLDCARTS, which walks through when the headaches began, where they sit, how long they last and what changes them.