Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:__4-4-2020___ Patient Information Patient Initials A.B. Age 18 Sex F Chief Complaint Wellness exam History of Present Illness (HPI) A.B., an 18-year-old female here today for a comprehensive wellness exam. States she does not have any concerns at this time. She is a senior in high school and active in lacrosse. She works 30-35 hours per week at Dairy Queen. Patient is slightly overweight. States she has been making healthier meal choices and not eating at work as much and has recently lost around 20 pounds over a 5-month period. History of Factor V Leiden without history of blood clots. No history of pregnancy. 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Depo Provera, IM, every 3 months Tylenol 500mg, 2 tablets as needed for pain Ibuprofen 200mg, 2-3 tablets as needed for pain Allergies Bactrim- rash Medical HX (PMH) 1
Childhood Pretty healthy. Broken foot from jumping off bed and broken arm from falling out of wagon. Adult Factor V Leiden Surgical Wisdom teeth Ob/Gyn No pregnancies, Depo Provera injection for painful menses Psychiatric No history of depression, anxiety or suicidal thoughts Vaccinations Flu Date: 11,2019 Pneumovax Date: NA Tetanus Date: Up to date Family HX (specify family member affected/age at death) Grandpa (paternal)- died at 62 years old of lung and brain cancer Grandpa (maternal)- Hx of heart attack, kidney- left kidney removed Grandmother’s- alive and well Father- alive and well Mother- Alive and well. Hx Factor V Leiden 1 sister- Alive and well. Hx Factor V Leiden 1 brother- Alive and well Social/Environmental HX HTN DM Ca MI/CAD CVA TB Renal dz Thyroid dz Suicide Alcoholism Substance abuse Born in : Grand Rapids, MN Education : Senior in high school Occupation : Student and works at Dairy Queen as a shift lead Family situation : Lives with mom, dad and siblings- all very close Transportation options : Owns car Insurance : Medical, dental and car insurance through parents Neighborhood : Rural/country Language/Literacy : English/able to read, write and understand 2
directions Access to emerging technologies: owns iPhone, family computer Interests/Hobbies : being with friends and family, lacrosse 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 Slightly overweight. Recently lost 20 pounds in last 5 months 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- last eye exam 3 years ago Ears Hearing Δ; tinnitus; earaches; infections; discharge Negative Nose/ Sinuses Colds; congestion; discharge; itching; hay fever; nosebleeds Negative Throat
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- Spring '16
- Shelley Ashby
- pulse, factor V Leiden