comprehensive assessment wayne3.docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date Patient

comprehensive assessment wayne3.docx - Advanced Nursing...

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate: 09/03/2018Patient InformationPatient InitialsWSAge57 SexMaleChief ComplaintNew Patient appointment annual assessmentHistory of Present Illness (HPI)Assessment completed on the 57 y/o male with h/o hyperlipidemia, and otherwise healthy. Currently denies pain, no complaints. 7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsDaily VitaminAllergiesNo Known AllergiesMedical HX (PMH)ChildhoodConstipationAdultN/ASurgicalN/AOb/GynN/APsychiatricN/AVaccinationsFluDate: 2017Pneumovax Date: N/ATetanusDate: N/AFamily HX (specify family member affected/age at death)Family: All except father and a sister in immediate family living. Paternal and 1
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Maternal grandparents deceased, cause of death unknown. Father passed away of lung CA and CVASister passed at birthMother living with HTNBrothers with Hx of HTN, and HyperlipidemiaSocial/Environmental HXHTNDMCaMI/CADCVATBRenal dzThyroid dzSuicideAlcoholismSubstance abuseBorn in:Lima, OhEducation: High School Graduate, GED, some collegeOccupation:Manager of Environmental ServicesFamily situation:Married with 5 children, and 11 grandchildrenTransportation options: DrivesInsurance:Has insurance via employerNeighborhood:Lives in rural community Language/Literacy:EnglishAccess to emerging technologies:Yes, has smart phone,and computersInterests/Hobbies:Fishing, and walkingSocial- Non- smokerReview 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 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; scotomaGlasses, last eye exam 2017. NegativeEarsHearing Δ; tinnitus; earaches; 2
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infections; dischargeNegativeNose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsNegativeThroatBleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarseNegativeNeckLumps; 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; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intoleranceNegativeUrinaryFrequency; nocturia; urgency; dysuria;hematuria; incontinenceMALES: caliber of urinary stream; hesitancy; dribblingNegative G/U (General)Sexual habits; interest; function;
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