C350 Health Assessment.docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date February 8 2017 Patient

C350 Health Assessment.docx - Advanced Nursing Practice...

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date: February 8, 2017 Patient Information Patient Initials JLR Age 35 Sex M Chief Complaint Patient 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 better Quality : Symptoms include feeling jittery, pounding in chest, feeling as if he has “lost” his breath and slight confusion Region : Generalized Severity : Varies Timing : Throughout the night. States not as frequent during the day 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Lisinopril 40mg PO daily Atorvastatin 20mg PO daily Glipizide 10mg PO daily Chlorthalidone 25mg PO daily Wellbutrin 150mg PO daily Atenolol 50mg PO daily Allergies NKDA NKFA
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Medical HX (PMH) Childhood Penumonia Adult T2DM dx 1999, HTN dx 2014 Surgical Denies Ob/Gyn N/A Psychiatric Panic Attacks dx 2016 Vaccinations Flu Date: 10/15/2016 Pneumovax Date: Unknown Tetanus Date: Unknown Family HX (specify family member affected/age at death) Mom T2DM HTN Dad T1DM Currently on dialysis Cancer (unsure of origin) HTN Generalized weakness ERD Heart Attack 2016 Social HX HTN DM Ca MI/CAD CVA TB Renal dz Thyroid dz Suicide Alcoholism Substance abuse Born in: Richmond Virginia Education: High School Occupation: Self Employed Family situation: Married w/1son Habits: No cigarettes but states does drink beer daily Interests/Hobbies: Cooking, video games, sports
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Review of Systems (ROS) List findings, or check as negative. (If you have a positive finding, then describe its seven attributes in the HPI or PMH) Concerning Symptom Findings General Wgt Δ; weakness; fatigue; fevers Negative Skin Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails Negative Head Headache; head injury; dizziness Negative Eyes Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma Corrective lenses. Negative for blurred/double vision, pain, redness or excessive tearing Ears Hearing Δ; tinnitus; earaches; infections; discharge Negative Nose/ Sinuses Colds; congestion; discharge; itching; hay fever; nosebleeds Negative Throat Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse Last dental exam September 2016. Denies bleeding gums, sore throat or dry mouth Neck Lumps; swollen glands; goiter; pain; neck stiffness Negative Breasts Lumps; pain; discomfort; nipple discharge Negative Pulmonar y Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains
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