CHAD2.doc.docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date Patient Information Patient Initials

CHAD2.doc.docx - Advanced Nursing Practice Field Experience...

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date:__1/6/2020________ Patient Information Patient Initials J.M. Age 24 Sex F Chief Complaint Wellness physical History of Present Illness (HPI) No current illness 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications None Allergies Peanuts NKMA Medical HX (PMH) 1
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Childhood None Adult None Surgical None Ob/Gyn G1P1, 1 NSVD Psychiatric None Vaccinations Flu Date:10/2019 Pneumovax Date:n/a Tetanus Date:2019 Family HX (specify family member affected/age at death) Paternal grandmother brca 2 positive breast cancer still living age 77 Mother and sister alcoholism both still living ages 47 and 21 respectively Social/Environmental HX HTN DM Ca MI/CAD CVA TB Renal dz Thyroid dz Suicide Alcoholism Substance abuse Smokes ½ PPD x 2 years Born in: US Education: attending college Occupation: college student Family situation: lives with spouse and son Transportation options: private Insurance:private Neighborhood: safe/rural community Language/Literacy: English, appropriate for college attendee Access to emerging technologies: adequate access to internet etc 2
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Interests/Hobbies: school, appropriate for age and situation 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 No recent unintentional weight changes, denies fatigue or fevers Skin Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails Skin free of rashes, sores, denies itching or dryness, no changes in hair or nails Head Headache; head injury; dizziness Denies headache or dizziness, no history of head injury, no obvious deformities Eyes Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma No recent vision changes, wear glasses, last eyes exam June of 2019, denies blurred or double vision. No redness or tearing noted. No signs of eye infections or needs for further follow up or change of prescription warranted at this time Ears Hearing Δ; tinnitus; earaches; infections; discharge Denies hearing changes, ringing, or pain in ears. 3
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No discharge noted. Nose/ Sinuses Colds; congestion; discharge; itching; hay fever; nosebleeds Recent cold with mild head congestion x2 days, no discharge noted. No nosebleeds or hay fever Throat Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse Denies bleeding gums, sore throat or tongue. No hoarseness noted. Last dental exam last year. Neck Lumps; swollen glands; goiter; pain; neck stiffness Denies neck pain or stiffness. No swollen glands or lymph nodes noted. Neck movement wnl.
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