98%(164)160 out of 164 people found this document helpful
This preview shows page 1 - 4 out of 12 pages.
Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate: February 8, 2017Patient InformationPatient InitialsJLRAge35SexMChief ComplaintPatient stating having issues with his blood sugar dropping at night and occasionally during the day.History of Present Illness (HPI)Began about 1 month ago, wakes up several times per night feeling jittery. Reports when checks his blood sugar, the levels range from 65-75 despite having eaten a large meal for dinner and having a before bedtime snack. Symptoms include feeling jittery, pounding in chest, feeling as if he has “lost” his breath and slight confusion. Palliative: Eating and taking long, deep breaths make the symptoms betterQuality: Symptoms include feeling jittery, pounding in chest, feeling as if he has “lost” his breath and slight confusionRegion: GeneralizedSeverity: VariesTiming: Throughout the night. States not as frequent during the day7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsLisinopril 40mg PO daily Atorvastatin 20mg PO dailyGlipizide 10mg PO dailyChlorthalidone 25mg PO dailyWellbutrin 150mg PO dailyAtenolol 50mg PO dailyAllergiesNKDANKFA
Medical HX (PMH)ChildhoodPenumoniaAdultT2DM dx 1999, HTN dx 2014SurgicalDeniesOb/GynN/APsychiatricPanic Attacks dx 2016VaccinationsFluDate: 10/15/2016PneumovaxDate:UnknownTetanusDate:UnknownFamily HX (specify family member affected/age at death)MomT2DMHTNDadT1DM Currently on dialysis Cancer (unsure of origin)HTN Generalized weaknessERD Heart Attack 2016Social HXHTNDMCaMI/CADCVATBRenal dzThyroid dzSuicideAlcoholismSubstance abuseBorn in: Richmond VirginiaEducation: High SchoolOccupation: Self EmployedFamily situation: Married w/1sonHabits: No cigarettes but states does drink beer dailyInterests/Hobbies: Cooking, video games, sports
Review of Systems (ROS)List findings, or check as negative.(If you have a positive finding, then describe its seven attributes in the HPIor PMH)Concerning SymptomFindingsGeneralWgt Δ; weakness; fatigue; feversNegativeSkinRash; lumps; sores; itching; dryness; color change; Δ in hair/nailsNegativeHeadHeadache; head injury; dizzinessNegativeEyesVision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotomaCorrective lenses. Negative for blurred/double vision, pain, redness or excessivetearing EarsHearing Δ; tinnitus; earaches; infections; dischargeNegativeNose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsNegativeThroatBleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarseLast dental exam September 2016. Denies bleeding gums, sore throat or dry mouth NeckLumps; swollen glands; goiter; pain; neck stiffnessNegativeBreastsLumps; pain; discomfort; nipple dischargeNegativePulmonaryCough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains