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NR-302 Health Assessment Comprehensive Head-to-Toe Assessment File Bundle Update

Student Information  Student Name: ____________________________  Course: NR-302 Health Assessment I (LB)  Instructor: Elaine Vierra, MS  Date of Assessment: _____________________ ...  Patient Initials: J.D.  Age: 45 years  Gender: Female  Setting: Outpatient Primary Care Clinic SUBJECTIVE DATA (S) Chief Complaint (CC) "I’ve been feeling very tired lately and get headaches a few times a week." History of Present Illness (HPI) J.D. is a 45-year-old female presenting with complaints of persistent fatigue for approximately 2 months and intermittent frontal headaches occurring 2–3 times per week. Fatigue is described as constant, worse in the afternoons, and not relieved by rest. Headaches are rated 4/10, dull, non radiating, and relieved with over-the-counter acetaminophen. Denies nausea, vomiting, photophobia, fever, dizziness, chest pain, shortness of breath, or recent illness. Reports increased work stress and decreased sleep (approximately 5–6 hours per night). Past Medical History (PMH)  Hypertension (diagnosed 5 years ago)  Seasonal allergic rhinitis Surgical History  Appendectomy at age 22 Medications NR-302 Health Assessment I (LB) Comprehensive Head-to-Toe Assessment File (SOAP Format) Update  Lisinopril 10 mg PO daily  Loratadine 10 mg PO daily PRN allergies  Acetaminophen 500 mg PO PRN headache Allergies  NKDA (No known drug allergies) Family History  Father: Hypertension, type 2 diabetes  Mother: Hypothyroidism  No family history of cancer or heart disease Social History  Occupation: Office administrator  Lives with spouse  Denies tobacco use  Drinks alcohol socially (1–2 drinks/week)  Denies illicit drug use  Exercises occasionally (walking 1–2 times/week) Review of Systems (ROS) General: Reports fatigue; denies fever, chills, weight loss Skin: Denies rashes, lesions, itching HEENT: Headaches present; denies vision changes, hearing loss, sore throat Respiratory: Denies cough, dyspnea Cardiovascular: Denies chest pain, palpitations, edema Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation Genitourinary: Denies dysuria, frequency, hematuria Musculoskeletal: Denies joint pain or stiffness Neurological: Denies dizziness, weakness, numbness Psychiatric: Reports stress; denies depression or anxiety [Show More]

Last updated: 8 months ago

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