C 350 Comprehensive_Health_Assessment_Documentation_Form_(0416).docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment

C 350 Comprehensive_Health_Assessment_Documentation_Form_(0416).docx

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:_October 10, 2018_________Patient InformationPatient InitialsSFAge48SexMChief ComplaintPatient denies any acute complaint. Pt is requesting a comprehensive health assessment as part of his annual physical examination.History of Present Illness (HPI)HPI: no specific complaintsLocation: noneQuality: noneSeverity: noneTiming: noneSetting: noneRemitting / exacerbating factors: noneAssociated manifestations: none7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsPatient reports no current medicationsAllergiesNo known drug allergies1
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Medical HX (PMH)ChildhoodChicken pox (unknown age). Denies any other illnesses.AdultDenies any acute or chronic medical conditionsSurgicalJaw surgery age 19 (atraumatic)Gallbladder removed mid-30s (no complications)Ob/GynN/APsychiatricPatient denies any psychiatric illness; denies depression; denies loss of interest in normal activitiesVaccinationsFluDate: 08/2018PneumovaxDate: has not receivedTetanusDate: 06/2014Family HX (specify family member affected/age at death)Mother and father both still living, both in good health.Maternal grandmother died from a stroke in her 60s.Denies any history of cardiac disease, HTN or diabetes in family.2
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Social/Environmental HXHTNDMCaMI/CADCVATBRenal dzThyroid dzSuicideAlcoholismSubstance abuseBorn in: Honolulu, HawaiiEducation: Associates DegreeOccupation: Retail ManagementFamily situation: Married, 3 childrenTransportation options: Own vehicleInsurance: yesNeighborhood: Rural; owns homeLanguage/Literacy: English; able to read and writeAccess to emerging technologies: yesInterests/Hobbies: Gaming; family activities; outdoor recreation equipment3
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Review of Symptoms (ROS)List findings, or check as negative.(If you have a positive finding, then describe its seven attributes inthe HPI or 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; scotomaNegativeLast eye exam 1 month ago (employment)EarsHearing Δ; tinnitus; earaches; infections; dischargeNegativeNose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsNegativeThroatBleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarseNegativeLast dental exam 3 months agoNeckLumps; swollen glands; goiter; pain; neck stiffnessNegativeBreastsLumps; pain; discomfort; nipple dischargeNegativePulmonaryCough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic painsNegativeCardiacChest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edemaNegativeG/IAppetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain;
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