Comprehensive Health Assessment Documentation Form.docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form

Comprehensive Health Assessment Documentation Form.docx -...

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:___12/9/2019_______ Patient Information Patient Initials NAM Age 47 Sex Male Chief Complaint Denies complaint, here for routine physical. History of Present Illness (HPI) Headaches: mild head pain, 2 to 3 times a week, any time of day in various situations, OTC meds make it better. Visual changes: slight changes over last few months, wears reading glasses for reading, vision is improved with reading glasses. Heartburn: stomach and esophagus, mild to moderate after most meals, eating greasy and spicy foods makes it worse, resolved with taking Prilosec. Kidney Stones: pain in ureters and urethra, mild to severe pain, once every 1-2 years, drinking tea and soda make occurrence more frequent, pain is resolved when stone is passed. Back pain: after work and with heavy lifting, pain is 5/10, occurs after heavy lifting, Advil and rest resolve pain. 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Prilosec 20mg 1x/day For heartburn Advil OTC 2-3X/week As needed for pain, headaches and back pain Lisinopril 10mg discontinued Allergies 1
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NKA NKDA Medical HX (PMH) Childhood Appendectomy 7 th grade, Leg fracture 1986 playing soccer, able to resume normal physical activity, received all childhood vaccinations Adult Kidney stones, Opiate addiction- rehab 4 times on relapse in 5 years Surgical Appendectomy in 7 th grade, required hospital stay. Vasectomy 2003- no complications Ob/Gyn Male patient Psychiatric Depression with addiction, no depression or anxiety now Vaccinations Flu Date:no Pneumovax Date:no Tetanus Date:2018 Family HX (specify family member affected/age at death) Paternal grandfather- heart attack, kidney stones (requiring part of kidney to be removed) died in his 70s Maternal grandfather complications from Malaria made him ill during his life, died in his 40s Maternal grandmother- cancer died at age of 94. Social/Environmental HX xHTN DM Ca MI/CAD CVA TB Renal dz Thyroid dz Suicide Alcoholism xSubstance abuse Born in: Portland IN Education: Bachelor’s Degree Occupation: Propane Delivery Family situation: Lives with wife and 3 children Transportation options: Has 5 cars, no difficulty with transportation 2
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Insurance: Has medical, vision, and dental. Neighborhood: Overall safe neighborhood with some theft in the past. Language/Literacy: Speak English and able to read. Access to emerging technologies: Has access to the internet if needed for electronic health record. Interests/Hobbies: Goes to church, likes landscaping and mowing yards. Enjoys spending time with his family. 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 Headaches occasionally 3
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