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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation FormDate:__10/16/19_____Patient InformationPatient InitialsDSAge26 years oldSexMaleChief ComplaintWellness exam to establish new care providerHistory of Present Illness (HPI)Last wellness exam was 10 months ago with former primary care provider7 attributes of a symptom: location, quality, quantity/severity, timing, setting,remitting/exacerbating factors, associated manifestationsMedicationsKeppra 1500mg twice a dayAllergiesNo known allergiesMedical HX (PMH)ChildhoodChickenpox in lower grade school, unsure of exact ageAdultEpilepsy, diagnosed 2016SurgicalDenies surgical historyOb/GynDenies OB/GYN history, patient is malePsychiatricDenies psychiatric historyVaccinationsFluDate: 2016PneumovaxDate: deniesTetanusDate: 2019Family HX (specify family member affected/age at death)Father – stent in heart.1
Mother – no major medical historyPaternal grandfather – died of heart disease/myocardial infarction at 52 yrs oldPaternal grandmother – died of old age/Alzheimer’s disease at 84 yrs oldMaternal grandfather – alive and healthy, 80 yrs oldMaternal grandmother – alive and healthy, 78 yrs oldSocial/Environmental HXHTNDMCaMI/CADCVATBDenies allRenal dzThyroid dzSuicideAlcoholismSubstance abuseDenies drug use, denies alcohol consumption, denies suicidal/homicidal ideations, no history of renal or thyroid diseaseBorn in:a hospital in Kalamazoo, MI, 1993Education:bachelor’s degree in computer scienceOccupation:software engineerFamily situation:married, no kidsTransportation options:owns anddrives own carInsurance:fully coveredNeighborhood:suburban, safe, lowcrime, ethnically diverse, close to major citiesLanguage/Literacy: English-speaking, above average literacyAccess to emerging technologies: yes, patient is technology savvyInterests/Hobbies: woodworking, restoring classic cars, building computersReview 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 SymptomFindingsGeneralWt Δ; weakness; fatigue; feversIntentional wt loss, on diet8 wks, 20 lbs lost. Denies weakness, fatigue, fevers.SkinRash; lumps; sores; itching; dryness; color change; Δ in hair/nailsDenies rash, lumps, sores,itching, dryness, color change, or changes in hair/nailsHeadHeadache; head injury; dizzinessDenies headaches, head injury, or dizzinessEyesVision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotomaCorrective lenses, last eyeexam 06/2019Denies vision changes, eye pain, redness, excessive tearing, double vision, blurred vision, scotoma2
EarsHearing Δ; tinnitus; earaches; infections; dischargeDenies hearing changes, tinnitus, earaches, infections or discharge from earsNose/SinusesColds; congestion; discharge; itching; hay fever; nosebleedsDenies colds, congestion, discharge from nose, itching, hay fever, or nosebleedsThroatBleeding gums; dentures; last dental