96%(24)23 out of 24 people found this document helpful
This preview shows page 1 - 5 out of 12 pages.
Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:9/29/2019Patient InformationPatient InitialsA.H.Age37SexFemaleChief ComplaintNo complaints of illnessHistory of Present Illness (HPI)Uterine Fibroid Tumors since 20187 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsVitamin C- 500mg dailyVitamin D- 1000 I U DAILYL-Lysine 1000mgAllergiesMorphineBenadrylMedical HX (PMH)ChildhoodNo childhood disease1
AdultNegativeSurgicalNegativeOb/GynUterine Fibroid TumorsPsychiatricNegativeVaccinationsFluDate:10/18PneumovaxDate: refuseTetanusDate: up-to -dateFamily HX (specify family member affected/age at death)Mother has hypertensionFather has Diabetes Type 2Maternal Grandmother unknownPaternal Grandfather unknownSocial/Environmental HXHTN- naDM-naCa-naMI/CAD-naCVA- naTB- naRenal dz naThyroid dz- naSuicide- naAlcoholism-naSubstance abuse-naBorn in: Detroit, MichiganEducation: High school Graduate/ 2 years of collegeOccupation: NurseFamily situation: Single/ no childrenTransportation options: Reliable CarInsurance:Blue Cross Blue ShieldNeighborhood: safe/ Suburban areaLanguage/Literacy: EnglishAccess to emerging technologies:Iphone, MacbookInterests/Hobbies: painting, creatingjewelry, drawing, exercise, movie 2
goerReview of Systems (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; feversNEGATIVE SkinRash; 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; scotomaLast eye exam 9/19Wears corrective lensesEarsHearing 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 APPOINTMENT 6/2019 NeckLumps; 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; edemaNEGATIVE3
G/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; dribblingNEGATIVEG/U (General)Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposureNEGATIVEMale G/UDischarge from or sores on penis; testicular pain/massesNAFemale G/U