| Course | NU 610 Advanced Health Assessment |
|---|---|
| Unit | Unit 1 |
| Paper type | Comprehensive health history write-up |
| Length | About 1,310 words, 7 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | MSN Family Nurse Practitioner |
| Updated | October 2026 |
Free sample paper for NU 610 Unit 1
Comprehensive Health History: A 61-Year-Old Man With Ankle Swelling and Nighttime Breathlessness
Student Name
Department of Nursing, Herzing University
NU 610: Advanced Health Assessment
Instructor Name
February 9, 2026
Comprehensive Health History: A 61-Year-Old Man With Ankle Swelling and Nighttime Breathlessness
Identifying Data and Reason for Visit
Mr. D. is a 61-year-old retired city bus driver who lives with his wife in a second-floor apartment. He is the source of this history and is judged reliable; his wife was present for part of the interview and added two details that are marked where they appear. This is a composite patient built for teaching, and no part of the record comes from a real encounter.
Chief complaint: "My ankles are puffy every night and I've started sleeping in the recliner because lying flat makes me feel like I can't get a full breath."
History of Present Illness
Mr. D. first noticed swelling around both ankles about seven weeks ago, when the tops of his work boots began leaving a deep line by late afternoon. The swelling is always on both sides, worse on the right according to his wife, and it is least noticeable when he wakes. By evening it reaches just above the ankle bones. He describes it as heavy and tight rather than painful and rates the discomfort at 3 out of 10. Elevating his feet on a stool for an hour in the evening softens it but does not make it go away.
About four weeks ago he began waking around 2 a.m. short of breath, sitting up on the edge of the bed for ten to fifteen minutes until it passed. He now sleeps on three pillows, and for the past nine nights he has slept in a recliner. He reports that he can climb one flight of stairs to his apartment but has to stop at the landing, which he did not have to do last spring. He estimates he could walk about two blocks on level ground before needing to rest. He has gained what he believes is 9 pounds in two months without eating more.
He denies chest pain, chest pressure, and pain radiating to the arm or jaw, including during stair climbing. He denies palpitations, fainting, and near fainting. He reports a dry cough, worse at night, for about three weeks. He denies fever, chills, sputum, and blood in anything he has coughed up. He denies calf pain, recent long car or plane trips, and recent surgery. He has not tried any medication for the swelling and has not changed the amount of salt he uses. He came in today because his wife insisted after he could not finish mowing a small section of lawn.
Past Medical History
Hypertension diagnosed about twelve years ago. Type 2 diabetes diagnosed eight years ago; he reports his last A1C "was around 8" but does not know the date. He had a heart attack at age 54 and was told a stent was placed; he does not know which artery and has not had cardiology follow-up for about three years. Obstructive sleep apnea was diagnosed four years ago; he stopped using the CPAP machine after roughly six months because the mask felt confining. No known kidney disease, although he recalls being told his "kidney number was a little high" at some point. No history of stroke, thyroid disease, liver disease, or cancer.
Surgical history: cardiac catheterization with stent placement at age 54; left inguinal hernia repair at age 40. Hospitalizations: the admission for the heart attack, three days, and none since. Immunizations: he believes he had an influenza vaccine last fall and is unsure of pneumococcal or shingles vaccination.
Medications and Allergies
Metformin 1,000 mg by mouth twice daily. Lisinopril 20 mg by mouth once daily. Atorvastatin 40 mg by mouth once daily at bedtime. Aspirin 81 mg by mouth once daily. Metoprolol succinate 50 mg by mouth once daily, which he admits he takes "most days." Ibuprofen 400 mg by mouth two or three times a week for knee pain, bought over the counter. No herbal products or supplements.
Allergies: sulfamethoxazole-trimethoprim, which caused a widespread itchy red rash in his thirties; no swelling of the lips or throat and no breathing difficulty with that reaction. No known food or latex allergies.
Family History
Father died at 66 of a heart attack and had diabetes. Mother is 84, living, with hypertension and heart failure diagnosed in her seventies. One older brother, 64, had coronary bypass surgery at 60. One younger sister, 57, has hypertension. Two adult sons, 34 and 31, both reported healthy. No known family history of sudden death before 50, cardiomyopathy, kidney disease, or clotting disorders. Paternal grandparents' histories are unknown to him; maternal grandmother had a stroke in her seventies.
Social History
Retired from bus driving two years ago after 30 years. Lives with his wife; they share cooking, and he estimates they eat takeout or canned soup four to five times a week. Smoked one pack per day from age 18 to 45, about 27 pack-years, and has not smoked since. Drinks two to three beers on weekend evenings and denies binge drinking. Denies cannabis or other drug use. Sleeps poorly because of the nighttime breathlessness and naps most afternoons. He was walking 30 minutes most mornings until about two months ago. He feels safe at home. He has Medicare and a supplemental plan and reports no trouble affording his medications.
Review of Systems
General: reports fatigue and 9-pound weight gain over two months; denies fever, chills, and night sweats. Skin: denies rashes, new lesions, and color change in the legs. Head and eyes: denies headaches and vision change; last eye examination over two years ago. Ears, nose, and throat: denies hearing change, nosebleeds, and sore throat. Respiratory: reports dry nighttime cough and breathlessness lying flat and on stairs; denies wheezing, sputum, and blood in sputum. Cardiovascular: reports ankle swelling and waking at night short of breath; denies chest pain, palpitations, and fainting.
Gastrointestinal: reports early fullness after meals for about three weeks; denies nausea, vomiting, abdominal pain, black stools, and change in bowel habits. Genitourinary: reports getting up twice a night to urinate, unchanged for several years; denies painful urination, blood in urine, and decreased urine output. Musculoskeletal: reports bilateral knee aching with long walks; denies joint swelling other than the ankles. Neurologic: denies weakness, numbness, speech change, and dizziness. Psychiatric: reports feeling "down about slowing down"; denies thoughts of self-harm. Endocrine: denies heat or cold intolerance and increased thirst. Hematologic: denies easy bruising and bleeding.
Gaps in This History
Three pieces of information could not be obtained today and are recorded as missing rather than guessed. Mr. D. could not recall which coronary artery was stented or whether an echocardiogram was ever done, so prior heart function is unknown. His most recent laboratory values, including kidney function and A1C, are not available to him. He also could not say how often he misses metoprolol doses beyond "a couple of times a week." Bickley et al. (2021) recommend that the written history separate what the patient reports from what cannot be confirmed, because an assumed value copied into a record becomes indistinguishable from a verified one. Records release forms for the cardiology practice and the prior primary care office were signed at this visit.
The review of systems above is deliberately written out body area by body area rather than closed with a single line claiming all other systems were negative. Ball et al. (2023) describe the systems review as a screen whose value lies in what was actually asked, and a condensed statement cannot show that. Dains et al. (2019) make a related point about pertinent negatives: the absence of chest pain and calf pain belongs inside the present illness because those negatives narrow the problem, and it belongs again in the screen because the screen documents breadth. No examination findings, vital signs, or measurements appear anywhere in this record; those belong to the objective record that follows it.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.
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.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.
NU 610 Unit 1 instructions, in plain terms
The Unit 1 assignment asks for a complete written health history on an adult, using the full set of headings a provider would use at an initial visit. Expect to document the chief concern in the patient's words, then a present illness that covers onset, location, duration, character, aggravating and relieving factors, and associated symptoms. Past history, medications, allergies, family history and social history all need their own headings, and the review of systems should run system by system. Many sections of the course supply a scenario or let you use a composite person; a real, identifiable patient should never appear. The write-up is graded as a record, so the language should read like a chart entry and not like an essay. Length is usually set in the classroom, and references to an assessment text are often required for the conventions you follow. Check whether a genogram or a separate source statement is expected.
How the NU 610 Unit 1 example is put together
The sample begins with identifying data and a reliability statement, noting that the wife added two details, which shows the grader how the informant was judged. The present illness then traces the swelling from the first boot line seven weeks ago to the pillows he now sleeps on, keeping time order intact. Medications appear with dose, route and frequency, and the paper records that he sometimes skips the beta blocker, a detail that changes how the swelling is read. Family history names ages and causes of death rather than a vague note about heart disease. The social history quantifies smoking at about 27 pack-years and describes a diet heavy in canned soup. The review of systems lists positives and negatives under each system. A final section on gaps names the stent details, prior heart imaging and a missing A1C date as items to request.
NU 610 Unit 1 rubric: what full points look like
Herzing rubrics for a history write-up usually award points across completeness, organization, accuracy of terminology, clinical relevance and professional writing. Completeness is often the heaviest criterion, and markers check that each required heading is present and filled with specific content. Organization earns points when the present illness reads in a clear time order and the review of systems stays separate from it. Terminology is scored on whether symptoms are described in standard clinical language without jumping to a diagnosis. Relevance points go to histories where the questions clearly follow the concern, such as orthopnea, paroxysmal nocturnal dyspnea and weight gain in a patient with swollen ankles. Writing points depend on concise chart phrasing, correct abbreviations and APA citations for the text conventions used. A short, honest list of missing information can lift the accuracy score because it shows judgment about what is known.
NU 610 Unit 1 help before you submit
The most frequent loss on this unit is a present illness that mixes in the review of systems, so the reader cannot tell what the patient came in for. Students also list medications without doses or forget to ask whether each one is actually taken. Family histories written as "positive for heart disease" lose points because they give no relative, age or outcome. Another problem is diagnosis creep, where the history states heart failure as a fact when only the symptoms are known at this stage. Smoking recorded as "former smoker" without pack-years is a small but common deduction. Some writers copy a template and leave headings filled with "noncontributory," which markers read as questions not asked. Finally, the gaps in a history should be stated plainly; inventing a lab value to fill a blank is worse than admitting it was not available.
Get a NU 610 Unit 1 example written to your instructions
Send us the Unit 1 instructions and the rubric posted in your NU 610 classroom, along with the case or patient scenario your section was given. We write a custom example against those exact points and return it in 24 to 48 hours. The first custom sample is free, and it sets the documentation standard for the units after it.
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NU 610 Unit 1 questions, answered
How long should a NU 610 health history write-up be?
Your instructions set the length, and sections differ. What drives it is completeness rather than a target: a history that pursues the present illness properly, records medications with dosing, reaches two generations of family history and writes out the systems screen will land where it lands. If your rubric names a page count, meet it by trimming commentary, not by compressing the record.
Can I use a real patient for this write-up?
Follow your instructions. Many sections supply a case or allow a consenting volunteer such as a family member, and some ask for a de-identified encounter. Anything you perform on a real patient, along with your clinical hours and the records your preceptor signs, belongs to you and is never something we draft. The example here is a shape for documentation, not a record of anyone.
What separates the present illness from the systems screen?
The present illness pursues one problem in depth and includes the negatives that narrow it. The screen sweeps every body area for anything the patient has not mentioned, and it is answered by the patient rather than observed by you. Anything you elicit with your hands belongs in the examination record instead. Mixing the three is the fastest way to give up organization points.
Where can I find a free NU 610 Unit 1 sample paper?
The complete NU 610 Unit 1 history is on this page and costs nothing to read, from the identifying data through the list of missing information, with margin notes beside each heading. For a version built on the scenario your section supplied, send the prompt through the request form and a custom draft comes back within about two days.
How do I write a health history for NU 610 Unit 1?
Start with the chief concern in the patient's words, then tell the present illness in time order with onset, character and associated symptoms. Add past history, medications with doses, allergies, family and social history, and a system by system review, and finish by naming anything you could not obtain.