Comprehensive Health Assessment

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COMPREHENSIVE WRITTEN ASSESSMENT

Complete Nursing Health History
Biographical Data
Name: B.R.
Address: xxxxxxx
Phone: xxxxx
Gender: Female
Provider of History: Client
Birth Date: February 2, 1973
Place of Birth: Portland, Oregon
Race: Caucasian
Educational Level: Associate’s Degree in Nursing and currently pursuing Bachelor’s of Science in Nursing Occupation: Registered Nurse
Significant Other: Fiancé “Mark”
Support Person(s): Mother & Brother
Reason for Seeking Healthcare
Client is currently seeking healthcare for her yearly routine physical. Client’s last check-up with her primary physician was one year ago, at which time, no abnormal findings were noted. Client is confident with her health at this time and she believes in being pro-active with her health and obtains a routine physical yearly for wellness and prevention. History of Present Health Concern

Client denies any concerns or health complaints. At this time, client is requesting a routine wellness check. Past Health History
Client denies any problems at birth. Client was adopted at three months old. Client had varicella as a child and currently is up to date on her immunizations. Client receives flu, tetanus, and pneumococcal immunizations at her workplace. Client admits to Adult Attention Deficit Disorder. Following a motor vehicle crash in 2005, client sustained a fractured tibia and fibula. Client subsequently had four tib/fib repair procedures. Client does report chronic back pain remedied by routine chiropractic care. Client is allergic to Sulfa and denies seasonal or environmental allergies. Family History

See Genogram for this client in Appendix A
Review of Systems for Current Health Problems
Skin, Hair, Nails: Normal skin color for race. Skin warm, dry, intact, no rashes, no lesions. No hair loss or dandruff. Head and Neck: Denies headache, stiffness, difficulty swallowing, enlarged lymph nodes. No pain. Ears: Denies pain, ringing, buzzing, drainage, difficulty hearing, dizziness or exposure to loud noise. Eyes: Denies pain, infections, halos, black spots, double vision, flashes or blurring. No redness noted. No drainage noted. Mouth, Throat, Nose and Sinuses: Denies pain, hoarseness, nasal obstruction, sneezing, coughing, snoring or epistaxis. Thorax and Lungs: Denies pain, difficulty breathing, exertional dyspnea, orthopnea, cough, infection or hemoptysis. Breasts and Regional Lymphatics: Denies pain, lumps, discharge, dimpling or change in breast size, swollen or tender lymph nodes in axilla. Heart and Neck Vessels: Denies chest pain or pressure, palpitations, edema. Unknown last blood pressure reading, unknown last ECG. Peripheral Vascular: Denies pain, swelling, sores to feet or legs. Legs and feet normal color for race. Abdomen: Denies pain, indigestion, difficulty swallowing, nausea or vomiting, gas, jaundice, or hernias. Male Genitalia: N/A

Female Genitalia: Denies pain, sexual pain, voiding pain or problems. Client started menstruating at age 13. No history of STD’s. No abortions. No pregnancies. No history of hormone replacement therapy. Anus, Rectum, Prostate: Denies pain, hemorrhoids, constipation, diarrhea, blood in stool. Bowel habits are normal. Musculoskeletal: Denies pain, swelling, redness, stiff joints. Strength of extremities is strong and equal bilaterally. Client cares for herself and is able to work without difficulty. Neurological: Client denies feelings of depression, anger or any mood changes. No loss of strength or sensation to body. Denies headache, concussions, or difficulty with coordination. No difficulty with speech, memory, strange thoughts or actions. No difficulties with reading or learning.

Lifestyle and Health Practices
Typical Day (24 hour review)
On a work day, client wakes around 5:45am and gets prepared to go to work for a 12 hour shift on a telemetry unit at a local hospital. Client works the 12 hour shift as a staff nurse....
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