Comprehensive Health Assessment Documentation Form submit for review 10. 8 (1).docx - Advanced Nursing Practice Field Experience Comprehensive Health

Comprehensive Health Assessment Documentation Form submit for review 10. 8 (1).docx

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:9/29/2019 Patient Information Patient Initials A.H. Age 37 Sex Female Chief Complaint No complaints of illness History of Present Illness (HPI) Uterine Fibroid Tumors since 2018 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Vitamin C- 500mg daily Vitamin D- 1000 I U DAILY L-Lysine 1000mg Allergies Morphine Benadryl Medical HX (PMH) Childhood No childhood disease 1
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Adult Negative Surgical Negative Ob/Gyn Uterine Fibroid Tumors Psychiatric Negative Vaccinations Flu Date:10/18 Pneumovax Date: refuse Tetanus Date: up-to -date Family HX (specify family member affected/age at death) Mother has hypertension Father has Diabetes Type 2 Maternal Grandmother unknown Paternal Grandfather unknown Social/Environmental HX HTN- na DM-na Ca-na MI/CAD-na CVA- na TB- na Renal dz na Thyroid dz- na Suicide- na Alcoholism-na Substance abuse- na Born in: Detroit, Michigan Education: High school Graduate/ 2 years of college Occupation: Nurse Family situation: Single/ no children Transportation options: Reliable Car Insurance:Blue Cross Blue Shield Neighborhood: safe/ Suburban area Language/Literacy: English Access to emerging technologies: Iphone, Macbook Interests/Hobbies: painting, creating jewelry, drawing, exercise, movie 2
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goer 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 Last eye exam 9/19 Wears corrective lenses 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 APPOINTMENT 6/2019 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 NEGATIVE Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema NEGATIVE 3
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G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance NEGATIVE Urinary Frequency; nocturia; urgency; dysuria; hematuria; incontinence MALES : caliber of urinary stream; hesitancy; dribbling NEGATIVE G/U (General) Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure NEGATIVE Male G/U Discharge from or sores on penis; testicular pain/masses NA Female G/U
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