Comprehensive history and physical worksheet

Your name:
LaDonna Henderson

Chief complaint (this is what the patient came in for if they have no particular complaints it may be
well visit, yearly physical or similar):
This is a well visit. No specific chief complaint noted.

History of present illness- MUST include the 10 characteristics of a chief complain OR list each and
note not applicable- you MUST specify WHAT the characteristics are please review your text, p. 47:
Location: N/A
Radiation: N/A
Quality: N/A
Quantity: N/A
Associated manifestations: N/A
Aggravating factors: N/A
Alleviating factors: N/A
Setting: N/A
Timing: N/A
Meaning and impact: N/A

Past medical/surgical history must include childhood illnesses, chronic illnesses/diseases,

injuries/accidents, blood transfusions, special needs, prior surgeries or asked and N/A you MUST
list each of these and describe in order to receive full credit. Do not leave it blank because it is
negative list it and then note none:
Childhood Illnesses: Measles, chicken pox, swimmers ear, strep throat
Chronic illnesses/diseases: Herpes simplex II
Injuries/accidents: Broken ankle (unknown cause), collar bone age 6 sister pushed down, age 12 bike
accident, hit in the head with an ax by another kid, received stitches, age 14
Blood transfusions: None
Special needs: None
Prior surgeries: Vasectomy 2001

Allergies: List food AND drug AND environmental offending agent AND reaction must be noted or
asked and N/A specified for each you MUST list out EACH of these and specify either none or the
allergen AND reaction to receive credit:
Drug allergies: None
Food allergies: None
Environmental allergies: Mild periodic seasonal allergies with symptoms of runny nose and itchy, watery
eyes

Current medications for each, list: Drug, Dose, Frequency, Reason for use, Length of use or asked
and N/A. Include both prescription and OTC meds. You can add rows to this table if you need to by
right-clicking on the bottom row and selecting insert rows below:
 Drug Dose Frequency Reason for Use Length of Use
Acyclovir 500 mg Once daily Prophylactic, 6 weeks
suppressant for
HSVII
Benadryl 25 mg Nightly Aid in sleep As needed off/on
for 10 years

Family health history include: age and health of children, siblings, parents; familial or genetic diseases-
at a minimum, note presence/absence of cancer, diabetes, heart disease. You can add rows to this table
if you need to by right-clicking on the bottom row and selecting insert rows below. You MUST fill in
each row for their family members so if there is no pertinent history, specify none. Make sure to
edit the family members in the column as appropriate, and include their age. :
Disease: Cancer Diabetes Heart Disease Other
Mother Lynchs Syndrome No No Deceased
Father No No H/o heart attack Age 78
Sibling Cervical/colon Sister, age 53
cancer
Sibling No No No Sister, age 54
Child No No No Son, age 21
Child No No No Daughter, age 18
Child No No No Daughter, age 14

Social history: ETOH use (type, amount, length of use, CAGE screen), Tobacco use (type, amount, length
of use), Drug use (type, amount, length of use), Presence/absence of domestic violence, sexual
orientation/birth control/number of partners (depending on the patient, this may be deferred, but
specify that you considered it and your rationale for deferring the question), type of employment,
education level, economic status:
CAGE Screen C A G E
(review p. 59 of
your text and Yes Yes Yes Yes
complete the four
sections to the
right):

Started drinking I knew my

at age 28. Drink of drinking was
choice: Captain alienating me
Morgan, 4 drinks from my children.
per day on a daily I drank to
 basis. Quit once at mentally and
38 for 3 years, emotionally
then again for escape my bad
good at age 45. relationship with
No alcohol intake my wife, but my
since. Attended kids paid the
Alcoholics price.
Anonymous for
six months.
Tobacco use: Type: Amount: Length of use:
Started at age 8 Cigarettes Occasionally as Quit in July 1989
available as a (age 25)
child; regularly as
an adult 1 pack
per day
Drug use: Type: Amount: Length of use:
No N/A N/A N/A
Presence/absence domestic violence? No domestic violence.
Sexual orientation? Primarily heterosexual; reports occasional
homosexual activity with two male friends
Birth control? Vasectomy Number of partners? Currently 2
Type of employment Education Level Socioeconomic Status

Full-time DBA (data base High school Upper middle class

administrator)

Spiritual assessment FICA (see p. 184 of your text for complete listing of questions):
Faith and Belief:
Do you consider yourself spiritual or religious? No.

Do you practice a specific faith? No.

Do you have spiritual/religious beliefs that help No.

you cope with stress?

What gives your life meaning? My children, my girlfriend, and my music. Has
played bass trombone since middle school and is
currently involved in two community bands.

Importance:
What importance does your faith or belief have Asked and N/A
in your life?
 Have your beliefs influenced how you take care Asked and N/A
of your health?

What role do your beliefs have in regaining or None

maintaining your health?

Community:
Are you part of a spiritual or None currently but does state he went to Alcoholics Anonymous
religious community? meetings when he quit drinking for the second time at age 45

Does this group support you? No; N/A

How?

Is there a group of people you Yes; my children and my girlfriend

really love or who are important
to you?

Address:
How would you like the healthcare team to I would like to include my girlfriend in my
address these issues in your healthcare? healthcare.

Cultural assessment EACAT (see p. 143-144 of your text for complete listing of questions):
Ethnic group affiliation and racial background:
Would you tell me how long you have lived here I have lived in Maryland for 22 years.
in_____?

Where are you from originally/where were you Riverdale, Maryland

born?

With which ethnic group do you identify? How Caucasian; strongly

strongly?

Where have you lived and when? Did you have Maryland until age 8, Virginia until age 12,
health problems or exposures in any of those Tennessee until age 21; South Carolina until age
places? How did you recover? 30, then moved to Maryland.

No heath problems or exposures.

Major beliefs and values:

What is your time orientation (past, present, Present
future?) What do you think is the basic nature of
human beings? What is the purpose of life and Innocuous and stupid
 human relations? What should be the
relationship between humans and nature?
Do you practice any special activities as part of
your cultural traditions?
What are your beliefs, customs, values, practices
related to work, education, leisure?
Health beliefs and practices:
What does being healthy mean to you?
What do you believe promotes being healthy?
What do you do to help you stay healthy?
What does being ill or sick mean to you?
What do you believe causes illness?
What do you usually do when you are sick or not
feeling well?
When you are sick or not feeling well, who do
you go to for help? How helpful are they, and for
what types of problems?
Who determines when you are sick or not? Who
do you want to be with you when you are sick?
Who in your family is responsible for making
healthcare decisions, and who should be involved
in teaching about your specific health problems?
Just to live my life.
Nature is there to be consumed. We dont have
any control over nature, only our environment.
None
I believe you should have a healthy balance of
all.
Not having any chronic medical issues.
Exercise and a good diet.
I try to eat well. Relates he has been
incorporating more salads into his diet.
Downtime. When asked to elaborate further,
stated that being sick means he has to take time
off work and activities.
Generally, microbes.
I dont get sick very often, but when I do, I
usually try to tough it out. Reports he rarely sees
a doctor when he does not feel well, but does get
a year physicial examination.
My girlfriend.
As helpful as she can be.
Mostly emotional problems; also reports he
sees a therapist twice a month (for the past 8
months) to discuss problems relating to his
divorce.
Me.
I want to be alone when I am sick.
Me.
Just me; does not wish anyone else to have
access to his medical information.
 What are your beliefs about mental illness,
chronic disease, handicapping conditions, pain,
dying, and death?
Are there any cultural or ethnic sanctions or
restrictions that you want to observe?
By whom do you prefer to have your healthcare
provided (nurse, physician, etc?). Do you prefer
them to be of the same cultural background, age,
or gender as your own?
Language barriers and communication styles:
What languages do you speak/read? In what
language are you most comfortable
communicating?
Do you prefer to have an interpreter when
discussing healthcare information and
treatments?
Are there any special ways of showing respect or
disrespect in your culture?
Are there any cultural preferences/restrictions
related to touching, social distance, eye contact,
or other verbal/nonverbal behaviors?
Are there culturally appropriate forms of greeting
or parting, topic restrictions, or visiting times?
Role of the family, spousal relationship, and parenting styles
What is the composition of your family? Who is
considered a family member?
With what ethnic groups does your family as a
whole identify?
Which of your relatives live nearby? With which
of your family members and relatives do you
interact most often?
How do your family members interact related to
chores, mealtimes, childcare, recreation, etc? Are
you satisfied with this?
What major events are most important to your
family, and how do you celebrate them?
I have no opinion on this subject.
No.
By whoever is qualified and speaks English as a
first languge. States he would rather his
healthcare provider be of the same cultural
background, age, and gender.
Speaks/reads English. Does not speak another
language.
Not applicable.
No.
Yes; dont invade my personal space. Reports
he feels uncomfortable when people do not look
him in the eye; does not like public displays of
affection; prefers a personal bubble of 3 feet.
Handshake.
I try not to discuss religon and politics.
I dont like people coming to my house uninvited
after 9 pm.
Me, my daughter, and my son. When prompted
regarding extended family, he included his father
and siblings (Well, some of them, sometimes).
Caucasian.
My second oldest sister lives about an hour
away.
My daughter and son the most; also my father.
My daughter has assigned chores. I expect her
to follow my instructions. We eat out a lot. I
would like to have more family dinners.
Birthdays, Christmas, and Thanksgiving. We
always celebrates birthdays by eating at Sakura.
Reports he and his children celebrate important

What are your familys goals for the health and
well-being of the whole family? What are your
future dreams? How do you work toward these?
What are the barriers?
How can the healthcare team help you work
toward these goals?
With what social groups (church, work, etc) does
your family interact, and what is the nature of
these interactions?
How does your family practice any special beliefs
related to marriage, conception, pregnancy,
childbirth, breastfeeding, baptism, childcare,
puberty, separation, divorce, health, illness,
death?
What are the family members health and social
histories - habits, major stressors, work patterns,
religion/community/recreation patterns?
Religious influences or special rituals; dietary practices - covered elsewhere and do not need to be
addressed here.
Nutritional assessment (see rubric, text table 7-7 on p. 220):
General diet information:
Do you follow a particular diet?
What are your food likes and dislikes?
Do you have any especially strong cravings?
How often do you eat fast food?
events by going out to eat together.
Reports both he and his daughter are in therapy.
His daughter has been seeing a therapist since his
divorce from her mother. He began therapy
about 8 weeks agoo after realizing that the
aftereffects of his divorce were still causing
problems in his life. He reports a good
relationship with his therapist and speaks
positively of his progress.
When asked about future dreams, he declined to
discuss them, stating, Im just trying to figure
out my present right now.
Asked and N/A.
Does not attend church. Was in the National
Guard and still socializes with this group. His
daughter is in Girl Scouts but is not as active as
she used to be. His son just finished college and
just got engaged.
Stated he came from a broken home and
always wanted to keep his children from
experiencing this. However, he was divorced six
years ago and states my marriage was over long
before then; I think I stayed married as long as I
did because I didnt want my kids to come from a
divorced home.
We are all pretty healthy. Reports he works
mostly from a home office which can be stressful
at times as he feels he does not have enough
separation between work and home life. He
enjoys spending time with his kids.
No
Im a meat and potatoes kind of guy.
I dont like mayonnaise or seafood.
Right now, everything. (He was prepping for a
colonoscopy the next day, so he had only been
able to eat clear liquids for the past 24 hours.)
5-6 times a week; way too much
 How often do you eat at restaurants?
Do you have adequate financial resources to
prepare your food?
How do you obtain, store, and prepare food?
Do you eat alone or with another family
member/person?
Do you consume any food supplements?
Reports going to a nice restaurant with either
his daughter or his girlfriend about once a
week.
Yes.
I usually shop at Sams Club because I have
plenty of pantry storage at home so I can buy it in
bulk. I am usually the one to cook our meals.
Sometimes my daughter or my girlfriend will
cook.
Usually with other people if I am eating out; I
dont eat out alone. At home, we eat at the
dinner table as often as we can. I think it is
important.
None.

In the past 12 months have you:

Experienced any changes in weight? None.

Had a change in your appetite? None.

Had a change in your diet? Yes, trying to eat more healthy since my last
physical.
Experienced nausea, vomiting, or diarrhea from None.
your diet?
Changed your diet because of difficulty in feeding N/A
yourself, eating, chewing, or swallowing?

Food intake history (24 hour diet recall) You can add rows to this table if you need to by right-clicking
on the bottom row and selecting insert rows below:
Time Food/drink Amount Method of Eating Location
Preparation
6:30 pm Taco salad from The whole thing Bought it at the In the car
Taco Bell, Diet drive-through on
Pepsi the way to my
band rehearsal
Soda 52 ounces
Water 8 ounces

Diet was limited

due to preparing
for a colonoscopy
the next day.
Health maintenance (must address sleep, exercise, stress management):
Sleep pattern: Generally less than 10 min to fall asleep but lately
has been having trouble falling asleep due to
increased stress at work. Sometimes it will take
an hour or more to fall asleep. Averages 6-7
hours of sleep per night. Usually awakens
refreshed but occasionally is fatigued the next
day.
Exercise: Reports he hates to exercies and only does so
when his girlfriend makes him. This usually
consists of brisk walking in his neighborhood.
Stress management: Honestly? I masturbate. It is the best stress-
reliever Ive found, especially since I dont drink
anymore.

Review of systems (make sure to include all pertinent positives/negatives) Remember that the review
of systems is ONLY subjective information that is, ONLY the history that the patient gives you, NOT
your physical examination. ALL exam findings go below, in the physical exam. Please review table 3-2
on p. 70-71 of your text:
General:
Generally in good health. Currently in his usual state. Energy level is low right now (preparing for
colonoscopy). No fevers, chills, or nightsweats.

Skin:
Dry skin in the wintertime. No change in color or size or moles. Always uses sunscreen when in the sun.

Hair:
Dry scalp in the wintertime. Uses over-the-counter medicated shampoo. Thinning hair on head as he has
gotten older.

Nails:
No splitting or damaged nails.

Eyes:
Wears trifocal corrective glasses, which become tinted in the sunlight. No blurred vision or photophobia.
Uses eye protection when using power tools and shooting his guns.

Ears:
No report of pain or discharge. No tinnitus or earaches. Uses ear protection when using power tools and
shooting his guns.

Nose and sinuses:

Seasonal hay fever with itchy watery eyes, sneezing, and postnasal drip. One cold in the past year. No
tinnitus or drainage.

Mouth:
Brush once a day, floss daily; two crowns, four fillings as a child. No change in taste.

Throat and neck:

No hoarseness. Does not get frequent sore throats. No difficulty swallowing.

Breasts and axilla:

No complaints of pain or tenderness. Does not do breast self-examinations.

Respiratory:
No shortness of breath, cough, or sputum production. No TB exposure or positive test result. Last PPD
was 3 years ago.

Cardiac:
No syncope, palpitations, or chest pain. Uses two pillows to sleep at night. Recent EKG done at last
physical showed no abnormalities.

Peripheral vasculature:
No hypertension or peripheral vascular disease. No claudication or history of DVTs. No problems with
leg cramps at night.

Gastrointestinal:
One benign polyp 10 years ago. Routine colonoscopy to be done tomorrow. No change in bowel habits;
usually has a bowel movement daily. No problems with diarrhea or constipation.

Urinary:
No difficulties with voiding. No dysuria or hematuria. No hesitancy, urgency, or frequency. No urinary
tract infections or kidney stones.

Musculoskeletal:
History of ankle and collarbone fractures. Does have some joint stiffness, particularly in the shoulders.
No limitation of movement.

Neurological:
No headaches, problems with balance or coordination, or head injury. No problems with memory or loss
of consciousness. No tics or tremors.

Psychological:
Some irritability and tension. Has had increased stress at work with some difficulty sleeping. No
depression or anxiety. No suicidal ideation.
Male or female reproductive:
Onset of puberty at 13. Healthy libido. Had a vasectomy. No pain during intercourse, no erectile
dysfunction. No enlarged prostate. Does monthly testicular self-examinations.

OK to defer nutrition, as this is addressed in depth elsewhere

Endocrine:
No recent weight change. No heat or cold intolerance. No problems with fatigue.

Lymph nodes:
No tenderness reported.

Hematological:
Blood type A+. Was exposed to radiation when installing x-ray machines at a previous job. I was not
always as diligent as I should have been. No easy bruising or bleeding. No history of blood transfusions.

Physical examination may defer breasts/genitalia/anus/rectum/prostate if appropriate. Remember

that in this section you will discuss ONLY exam findings no subjective information. All subjective
information goes in the review of systems. Please follow the exam guidelines on p. 1035-:
Constitutional/general survey:
Well-developed, overweight white male in no acute distress who appears his stated age. No obvious
deformities.

Measurements:
Height: 511; weight 229. Vital signs: Temperature 98.7, blood pressure 155/70 (right arm, sitting),
heart rate 78, Respirations 18.

Skin:
Skin color normal for ethnicity. Dry, scaly rash noted on right shin; otherwise skin intact.

Head and face:

Normocephalic. No lesions noted. No facial asymmetry.

Eyes:
Wears trifocal glasses. Pupils equal, round, and reactive to light and accommodation. Extraocular
movements intact with no nystagmus. No redness, inflammation, or discharge.

Ears:
Gross hearing intact to finger rub. External auditory canal clear with no drainage noted.

Nose and sinuses:

Nares patent. No nasal discharge or sinus tenderness.

Mouth and throat:

Oral mucosa pink, moist, and intact. Has own teeth in good repair. Lips pink. No lesions noted. Hard and
soft palate intact. Uvula midline.

Neck:
Supple with no masses or tenderness. Trachea midline. Thyroid nontender. No lymphadenopathy.

Upper extremities:
Full range of motion in shoulders, elbows, and wrists. No joint swelling. Strength 5/5. Capillary refill less
than 3 seconds. No edema. Sensation intact. Radial and brachial pulses 2+.

Back, posterior, lateral thorax:

Full range of motion of cervical spine. No evidence of scoliosis on examination.

Anterior thorax:
Good respiratory effort. No shortness of breath or use of accessory muscles. Lung sounds clear in all
fields anteriorly and posteriorly. No cough or sputum production.

Heart (note that the exam is divided between p. 1039-1040. Include all info in this section):
S1 and S2 noted. Regular rate and rhythm. No thrills or heaves noted. Apical pulse 77.

Breasts:
Deferred.

Jugular veins:
No JVD at 90 degrees, 45 degrees, or supine.

Abdomen/Gastrointestinal:
Soft, round, nontender. No scars or striae noted. Bowel sounds active and present in all four quadrants.
No guarding noted.

Inguinal area:
Declined.

Lower extremities:
Gait steady. Able to heel and toe walk. Capillary refill less than 3 seconds. Popliteal, dorsalis pedis, and
posterior tibialis pulses 2+. Skin warm and dry. Excoriated area on right shin from scratching. Full range
of motion. No lower extremity edema. Sensation intact. Strength 5/5.

Neurological system (note that the exam is divided between p. 1036 and two sections on p. 1041.
Include all info in this section):
Alert and oriented x4. Fund of knowledge appropriate for age and station. Attention span and memory
intact. Judgment and insight good. Thought processes linear and goal directed. Sensation intact to light
touch. Two-point discrimination intact. Able to perform finger to nose and rapid alternating hand
movement tests. Deep tendon reflexes intact. Able to hot on one foot and draw a figure 8 with both
feet.

Genitalia/anus/rectum/prostate:
Deferred.

Nursing diagnosis #1 (please review p. 8-10 of your text. There is a complete list of 2012-2014 NANDA
nursing diagnoses in the resources -> course materials):
Disturbed sleep pattern related to reported increased work stress as evidenced by difficulty falling
asleep, dependence on sleep aid, fatigue on awakening, and irritability.

Patient goal r/t nursing diagnosis #1 (make sure this is something MEASUREABLE how will you/they
know if theyve been successful? Within what timeframe?):
Patient will attain optimal amount of sleep as evidenced by self-report of decreased use of nightly sleep
aid to 4 times a week or less by next office visit in one month.

Nursing intervention r/t patient goal #1 (what will you do to help/support them?):

1. Help patient identify three relaxing diversional activities to help decrease stress.
2. Help patient establish a bedtime routine to facilitate falling asleep at night.
3. Encourage expression of feelings related to stressful work environment.

Nursing diagnosis #2 (please review p. 8-10 of your text. There is a complete list of 2012-2014 NANDA
nursing diagnoses in the resources -> course materials):
Imbalanced nutrition: more than body requirements as evidenced by BMI of 32 and self-reported
sedentary lifestyle.

Patient goal r/t nursing diagnosis #2 (make sure this is something MEASUREABLE how will you/they
know if theyve been successful? Within what timeframe?):
Patient will lose at least 4 pounds by next office visit in one month.

Nursing intervention r/t patient goal #2 (what will you do to help/support them?):

1. Help patient identify healthy diet choices.

2. Help patient identify ways to increase activity level during the workday.
3. Encourage patient to exercise at least 30 minutes on at least 5 days per week.