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:__10/16/19_____ Patient Information Patient Initials DS Age 26 years old Sex Male Chief Complaint Wellness exam to establish new care provider History of Present Illness (HPI) Last wellness exam was 10 months ago with former primary care provider 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Keppra 1500mg twice a day Allergies No known allergies Medical HX (PMH) Childhood Chickenpox in lower grade school, unsure of exact age Adult Epilepsy, diagnosed 2016 Surgical Denies surgical history Ob/Gyn Denies OB/GYN history, patient is male Psychiatric Denies psychiatric history Vaccinations Flu Date: 2016 Pneumovax Date: denies Tetanus Date: 2019 Family HX (specify family member affected/age at death) Father – stent in heart. 1
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Mother – no major medical history Paternal grandfather – died of heart disease/myocardial infarction at 52 yrs old Paternal grandmother – died of old age/Alzheimer’s disease at 84 yrs old Maternal grandfather – alive and healthy, 80 yrs old Maternal grandmother – alive and healthy, 78 yrs old Social/Environmental HX HTN DM Ca MI/CAD CVA TB Denies all Renal dz Thyroid dz Suicide Alcoholism Substance abuse Denies drug use, denies alcohol consumption, denies suicidal/homicidal ideations, no history of renal or thyroid disease Born in: a hospital in Kalamazoo, MI, 1993 Education: bachelor’s degree in computer science Occupation: software engineer Family situation: married, no kids Transportation options: owns and drives own car Insurance: fully covered Neighborhood: suburban, safe, low crime, ethnically diverse, close to major cities Language/Literacy: English- speaking, above average literacy Access to emerging technologies: yes, patient is technology savvy Interests/Hobbies: woodworking, restoring classic cars, building computers 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 Wt Δ; weakness; fatigue; fevers Intentional wt loss, on diet 8 wks, 20 lbs lost. Denies weakness, fatigue, fevers. Skin Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails Denies rash, lumps, sores, itching, dryness, color change, or changes in hair/nails Head Headache; head injury; dizziness Denies headaches, head injury, or dizziness Eyes Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma Corrective lenses, last eye exam 06/2019 Denies vision changes, eye pain, redness, excessive tearing, double vision, blurred vision, scotoma 2
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Ears Hearing Δ; tinnitus; earaches; infections; discharge Denies hearing changes, tinnitus, earaches, infections or discharge from ears Nose/ Sinuses Colds; congestion; discharge; itching; hay fever; nosebleeds Denies colds, congestion, discharge from nose, itching, hay fever, or nosebleeds Throat Bleeding gums; dentures; last dental
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