Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:2/26/2020 Patient Information Patient Initials CC Age 52 Sex M Chief Complaint Physical History of Present Illness (HPI) Annual physical 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Omeprazole Atorvastatin Naproxen Allergies NKDA Medical HX (PMH) 1
Childhood Exploratory laparotomy for internal bleeding. Appendix removed. Adult High cholesterol, GERD, arthritis in spine Surgical Exploratory laparotomy Ob/Gyn None Psychiatric None Vaccinations Flu Date: 10/2019 Pneumovax Date: Not received Tetanus Date: 12/2019 Family HX (specify family member affected/age at death) Father- heart disease, age at death 88 Social/Environmental HX HTN DM Ca MI/CAD CVA TB Renal dz Thyroid dz Suicide Alcoholism Substance abuse Born in: California Education: Associates degree Occupation: Police officer Family situation: Married, no kids Transportation options: Drives self Insurance: Insured Neighborhood: Rural Language/Literacy: English/Spanish Access to emerging technologies: Y Interests/Hobbies: Farming, dogs 2
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 Negative 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 Negative 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 G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; Negative 3
hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance 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 Negative Female G/U Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP Vaginal discharge; itching; sores;
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- pulse, bounding pulse , Wgu Health Assessment Analysis