C350 Comprehensive_Health_Assessment_Documentation_Form_(0717) (4) (1).docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment

C350 Comprehensive_Health_Assessment_Documentation_Form_(0717) (4) (1).docx

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:_9/22/2019_____ Patient Information Patient Initials RM Age 45 Sex Female Chief Complaint Patient presents today with request for a yearly physical. History of Present Illness (HPI) Patient present for physical, denies any health problems or needs. 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Patient does not take any medications. Allergies NKA Medical HX (PMH) Childhood Patient denies Adult Patient denies Surgical Patient denies Ob/Gyn Patient denies problem, unknown if patient is in care of OB/GYN 1
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Psychiatric Patient denies problems Vaccinations Flu Date: 2019 Pneumovax Date: 2019 Tetanus Date: 2019 Family HX (specify family member affected/age at death) Patient denies any family HX when asked Social/Environmental HX HTN DM Ca MI/CAD CVA TB Denies All Renal dz Thyroid dz Suicide Alcoholism Substance abuse Denies all Born in: unknown Education: associates degree Occupation: RN Family situation: lives at home with husband Transportation options: patient has car Insurance: patient reports having insurance Neighborhood: patient lives in rural area Language/Literacy: patient speaks English, college degree Access to emerging technologies: patient does have access to various technologies due to occupation Interests/Hobbies: unknown 2
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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 Patient denies Skin Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails Patient denies Head Headache; head injury; dizziness Patient denies Eyes Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma Patient does wear corrective lenses and states recently had eye exam; date unknown. Denies any changes with vision, pain, or redness Ears Hearing Δ; tinnitus; earaches; infections; discharge Patient denies Nose/ Sinuses Colds; congestion; discharge; itching; hay fever; nosebleeds Patient denies Throat Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse Patient denies Neck Lumps; swollen glands; goiter; pain; neck stiffness Patient denies Breasts Lumps; pain; discomfort; nipple discharge Patient denies 3
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Pulmonar y Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains Patient denies Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema Patient denies G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance Patient denies Urinary Frequency; nocturia; urgency; dysuria; hematuria; incontinence MALES : caliber of urinary stream; hesitancy; dribbling Patient denies G/U (General) Sexual habits; interest; function;
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