Comprehensive Health Assessment Documentation Form Revised.docx - Advanced Nursing Practice Field Experience Comprehensive Health Assessment

Comprehensive Health Assessment Documentation Form Revised.docx

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Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Date: 09/24/2019_ Patient Information Patient Initials F.M Age 41 Sex Male Chief Complaint None reported History of Present Illness (HPI) Patient is a 41-year-old African male presenting for general health examinations. Denies any complain today 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Medications Antihypertensive medications Allergies No known allergies to drugs or food 1
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Medical HX (PMH) Childhood None reported Adult hypertension Surgical Non reported Ob/Gyn Not applicable Psychiatric None reported Vaccinations Flu Date: date unknown “about 3 months ago” Pneumovax Date: Not known Tetanus Date: not known Family HX (specify family member affected/age at death) Mother (deceased); hypertension and cancer of the stomach Social/Environmental HX HTN Ca Born in Kenya Education: Bachelor Degree Occupation: Temporary Teacher Family situation: Married, House Transportation options: car Insurance: health insurance Neighborhood: relatively safe Language/Literacy: Can speak and write English Access to emerging technologies: smart phone, internet, computer Interests/Hobbies: running, soccer 2
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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 Patient denies problem Skin Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails None reported Head Headache; head injury; dizziness No reported symptoms Eyes Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma Patient denies problem Ears Hearing Δ; tinnitus; earaches; infections; discharge No reported symptoms Nose/ Sinuses Colds; congestion; discharge; itching; hay fever; nosebleeds No reported symptoms Throat Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse No reported symptoms Neck Lumps; swollen glands; goiter; pain; neck stiffness No reported symptoms Breasts Lumps; pain; discomfort; nipple discharge No reported symptoms Pulmonar y Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains No reported symptoms 3
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Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema No reported symptoms G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance No reported symptoms Urinary Frequency; nocturia; urgency; dysuria; hematuria; incontinence MALES : caliber of urinary stream; hesitancy; dribbling No reported symptoms G/U (General) Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure No reported symptoms Male G/U Discharge from or sores on penis; testicular pain/masses No reported symptoms Female G/U Menarche; frequency/duration of menses; dysmenorrhea; PMS
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