NKU MSN610 2020 March Module 7 Assignment Latest

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 7 Assignment

Northern Kentucky University

MSN 610: Diagnostic Reasoning and Advanced Physical Assessment

 

Comprehensive History & Physical Exam

DEMOGRAPHICS

 

Providers Name: ___________________________________ Patient’s Initials: (Data Source)____________________

 

Date of Exam: _______________________________________________________ Patient’s DOB: _______________

 

Chief Complaint:                                                                                         Gender/Sexual Orientation: ____________________

 

History of Present Illness:

 

 

 

Past Medical History:

                Active Problems:

 

 

                Resolved Problems:

                               

 

Previous Hospitalizations:

 

 

Surgical History:

 

 

Allergies:

 

Current Medications:

 

 

 

Social History:

                Living Arrangements:

 

                Occupation:

 

                Environmental Safety:

 

                Smoking:

 

                Alcohol:

 

                Drugs:

 

                Other Non-Prescribed Drugs:

 

Diet:

 

               

 

Family History:

 

Relationship Living or Deceased Age Illnesses Mother       Father       Children       Grandparents

 

 

Preventative Health/ Anticipatory Guidance: (Age Appropriate)

 

Safety Issues:

Screenings:

Immunizations:

 

Review of Systems:

 

General:

 

Skin, Hair, Nails:

 

HEENT:

 

Neck:

 

Cardiovascular:

 

Pulmonary:

 

Abd/GI:

 

Genitourinary/ Gynecology/ Breast

 

Musculoskeletal:

 

Neuro:

 

Endo/Lymphatic:

 

Hematology:

 

Psych:

 

 

Physical Exam  

Patient’s Initials: ________                                                                                                     Date of Exam: _________

 

Vital Signs:                          Temp:                        Pulse:                        BP:                           Resp:       

 

General Appearance:

 

Skin:

 

Head/Face:

 

Ears:

 

Eyes:

 

Nose:

 

Mouth/Throat:

 

Neck:

 

Heart:

 

Lungs:

 

Abdomen:

 

Musculoskeletal:

                Sensory:

 

                Motor:

 

Peripheral Vascular:

 

Neuro:

                Cranial Nerves:

               

                Reflexes:

 

Cognitive Function:                                                                       

 

Problem Presentation/Assessment Statement: (Summary of presenting problems)

 

 

Assessment:  Problem List (As many or as few as needed)

1)

 

2)

 

3)

 

Plan: