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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:___12/9/2019_______Patient InformationPatient InitialsNAMAge47SexMaleChief ComplaintDenies 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 manifestationsMedicationsPrilosec 20mg1x/dayFor heartburnAdvil OTC2-3X/weekAs needed for pain, headaches and back painLisinopril 10mgdiscontinuedAllergies1
NKANKDAMedical HX (PMH)ChildhoodAppendectomy 7thgrade, Leg fracture 1986 playing soccer, able to resume normal physical activity, received all childhood vaccinationsAdultKidney stones, Opiate addiction- rehab 4 times on relapse in5 yearsSurgicalAppendectomy in 7thgrade, required hospital stay.Vasectomy 2003- no complicationsOb/GynMale patientPsychiatricDepression with addiction, no depression or anxiety nowVaccinationsFluDate:noPneumovaxDate:noTetanusDate:2018Family HX (specify family member affected/age at death)Paternal grandfather- heart attack, kidney stones (requiring part of kidney to be removed) died in his 70sMaternal grandfather complications from Malaria made him ill during his life, died in his 40sMaternal grandmother- cancer died at age of 94.Social/Environmental HXxHTNDMCaMI/CADCVATBRenal dzThyroid dzSuicideAlcoholismxSubstance abuseBorn in: Portland INEducation: Bachelor’s DegreeOccupation: Propane DeliveryFamily situation: Lives with wife and 3 childrenTransportation options: Has 5 cars, nodifficulty with transportation2
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 inthe HPI or PMH)Concerning SymptomFindingsGeneralWgt Δ; weakness; fatigue; feversnegativeSkinRash; lumps; sores; itching; dryness; color change; Δ in hair/nailsnegativeHeadHeadache; head injury; dizzinessHeadaches occasionally3