Comprehensive history and physical worksheet

Your name:
Jessica Listman-Ward
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):
DOT physical
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:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Location- not applicable

Radiation- not applicable
Quality- not applicable
Quantity- not applicable
Associated manifestations- not applicable
Aggravating factors- not applicable
Alleviating factors- not applicable
Setting- not applicable
Timing- not applicable
Meaning and impact- not applicable

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:
Tonsillectomy age 11 at Kent/Queen Annes Hospital, Appendectomy age 9 at Kent/Queen Annes
Hospital, Hemorrhoid surgery age 30 at Kent/Queen Annes Hospital, Oil truck accident resulting in
flashback burns on hands that have healed but have scarring age 32, treated at Kent/Queen Annes
Hospital, HTN for 15 years, DM type 2 diagnosed in 2012, inguinal hernia since 2006,
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:
Seasonal allergies-hay fever, PCN-hives and GI upset
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
Lisinopril
25 mg
Once daily (AM)
Hypertension
15 years
Metformin
500 mg
Twice daily
DM-2
3 years
Aspirin
81 mg
Once daily (AM)
Heart health
5 years
OTC multivitamin 1 pill
Once daily
Multivitamin
15 years

Fish oil

2 capsules

Once daily (AM)

supplement
Heart health

5 years

Family health history include: age and health of children, siblings, parents; familial or genetic diseasesat 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
None
No personal
Mother is 89
Mental illnesshistory but
years old
schizophrenia
maternal
diagnosed 29
grandmother a
CHF, unsure of
years ago,
type 1 diabetic
age of onset but
Dementia
at least 15 years,
diagnosed in 2006
Father
None
None
Died at age of 70
Hypertension,
due to
unsure of onset
cardiomyopathy
but 15+ years of
treatment
Sibling
None
DM type 2,
Died at age of 40
Morbid obesity
diagnosed at age
from heart attack for 10+ years
20
Sibling
Child
None
None
None
One son-age 22
ADHD diagnosed
at age 10
Child
Maternal
Grandmother

None

DM type 1, died
due to
complications in
1969

None

None

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-Pt reports no A- Pt reports
G- Pt stated
E-Pt states he
(review p. 59 of
problem with
only drinking 1-2
during this exam
has never had a
your text and
alcohol intake,
drinks a month if
that he rarely
drink before 1pm,
complete the four states With CDL
that, states rare
drinks so since it
no issues with eye
sections to the
you must keep
beer with dinner
isnt all the time
opener drinking
right):
clean license
or cutting grass,
there isnt a need
No issues with
to feel guilty

Tobacco use:Never smoked

annoyance
Type:N/A

Amount:N/A

Length of use:N/A

Drug use:Never used drugs

Type:N/A

Amount:N/A

Length of use:N/A

Presence/absence domestic violence?

Denies any violence
Sexual orientation?
Heterosexual
Birth control?
Condoms
Number of partners?
Lifetime: 8, Current: 1
Type of employment
Education Level
Socioeconomic Status

Truck Driver

High School

Middle Class

Spiritual assessment FICA (see p. 184 of your text for complete listing of questions):
Faith and Belief:
Do you consider yourself spiritual or religious?
Patient reports that he grew up Methodist and
attended church but hasnt in 15 years, he does
report being spiritual
Do you practice a specific faith?
Grew up Methodist and most closely relates to
this faith
Do you have spiritual/religious beliefs that help
you cope with stress?

Occasionally uses power of prayer

What gives your life meaning?

Family

Importance:
What importance does your faith or belief have
in your life?

Pt reports that his beliefs have minimal

importance and impact on life

Have your beliefs influenced how you take care

of your health?

Pt states that his spiritual beliefs do not influence

or dictate health

What role do your beliefs have in regaining or

maintaining your health?

Pt states that he tries to maintain positive

attitude and healthy habits

Community:
Are you part of a spiritual or
religious community?

Not currently attending church or part of a community group

Does this group support you?

How?

Not applicable

Is there a group of people you

really love or who are important
to you?

Family and a few coworkers who are fellow truck drivers

Address:
How would you like the healthcare team to
address these issues in your healthcare?

Pt reports no issues with religion or spiritual

beliefs that need to be addressed

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
Pt has lived in Chestertown his entire life, 53
in_____?
years
Where are you from originally/where were you
born?

Pt is from Chestertown, MD and was born at Kent

and Queen Annes hospital in town

With which ethnic group do you identify? How

strongly?

Pt identifies with English ethnicity. He does not

have any other ethnic groups in his family
heritage. As a result he strongly relates to group.
Pt has only lived in Chestertown, MD. He had oil
truck accident and exposure to flammable
liquids. He has always recovered at home after
seeking appropriate medical treatment.

Where have you lived and when? Did you have

health problems or exposures in any of those
places? How did you recover?

Major beliefs and values:

What is your time orientation (past, present,
future?) What do you think is the basic nature of
human beings? What is the purpose of life and
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?

Pt is AOx4. He reflects on things from the past

saying that hindsight is always 50/50. He is
focused on the present and planning his future.
Pt states that he doesnt know the purpose of life
and relationships. He believes that everyone is
here for a reason but unsure what the reason is.
He believes that humans should respect mother
nature.
Pt reports that his family didnt eat meat on Good
Friday when he was growing up but he doesnt
follow that now.
Pt grew up in the firehouse. He started as a
junior member and worked his way up to
firefighter and FADO. His father and older
brother were members and his mother was in the
ladies auxiliary. He was part of a bowling team in

his early 20s which fostered his teamwork

abilities. He believes that hard work and honesty
should be used in the workplace. He believes in
the value of an education and that it is never too
late to go back to school.
Health beliefs and practices:
What does being healthy mean to you?

Pt reports that this means eating right, exercising

and feeling good about yourself.

What do you believe promotes being healthy?

Pt reports that eating 3 meals/day and not eating

a lot off processed and fattening food is healthy.

What do you do to help you stay healthy?

Pt reports weight lifting, walking, making better

food choices

What does being ill or sick mean to you?

Pt reports that it means feeling crappy and

does not like this feeling. He states that he
doesnt get sick often but when he does it hits
him hard.
Pt reports lack of eating good, not washing
hands, lack of sleep

What do you believe causes illness?

What do you usually do when you are sick or not

feeling well?

Pt reports that he sleeps

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?

Pt goes to doctor if issue is unresolved in a few

days. They treat him and give him medications if
needed. He also relies on family for support and
finds them helpful
Pt reports that he determines when he is sick and
if necessary he goes to doctor. He wants to be
with family for support when he is sick
Pt reports that he is responsible for health
decisions but discusses issues with significant
other. He relies on doctor to teach him about
health issues.
Pt believes that death is inevitable, it will happen.
He believes that mental illness isnt taken as
seriously as it should be. He had to deal with this
issue with his mother when he was younger.
Pt reports no

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?
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,

Pt prefers a doctor and states that age, culture

and sex do not matter.

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?

Pt only speaks English.

Pt has no need for interpreter

Pt reports using manners and handshake show

respect
Pt reports none.

Pt reports use of a handshake for formal

greeting. He reports that people he knows call
him by nicknames and he does the same. He has
no issues with topics or visiting times.

Role of the family, spousal relationship, and parenting styles

What is the composition of your family? Who is
Pt reports being a divorcee. His family is
considered a family member?
composed of his mother, son and significant
other. His brother and father are deceased. He
does not speak to a lot of his cousins as the
family had a falling out over 15 years ago. He
considers his pets family and treats close friends
like family.
With what ethnic groups does your family as a
Pt again reports identifying with English ethnicity.
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?

Pt reports that son lives 10 minutes away. He

visits his mother at nursing home every week and
that is 20 minutes from home. He sees his son a
few times a month now that he lives on his own
but they talk at least 2x/week. Pt sees his
significant others family monthly for dinner.
Pt reports being on the road most of the week so
he isnt home a lot. When he is they share
chores, cooking, etc. His son is grown and out of
the house so childcare isnt an issue. Pt reports
being ok with sharing household responsibilities.
Pt reports that his son and significant others
birthdays are important. They celebrate by going
to dinner as a family to their favorite restaurant.
He also reports that they celebrate their

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?

anniversary with a weekend trip to Pennsylvania

each year.
Pt reports that family would like to eat better and
exercise together. They would like to buy a
house within the next two years. They recently
achieved one goal for the year with buying a new
vehicle. They have created a budget and
eliminated extra spending to save for the big
expense. The big barrier for this goal is finances.
They need to pay off some of the larger bills so
that credit scores will improve. They plan on
reducing stressors so that their health will be
better both physically and emotionally.
Pt has already been educated on stress relieving
techniques by his doctor. His family interacts
with the firehouse as members. They give back
to the community with fire and EMS calls as well
as events.
Pt reports that the family goes to church for
baptism and celebrates together afterwards.
They believe in breastfeeding. In the event of a
death the family gets together and celebrates the
life of the one who passed by sharing stories.
Pt reports that significant other usually takes care
of everyone else first and then herself. She tends
to hold in stress. She works nights and sleeps
during day when she is working. She spends days
off at firehouse if pt is not home. She is working
on losing weight and trying to become healthier.
Finances are their major stressor. Pt lost job 3
years ago so they took a significant financial hit.
He is now working but was out of work for 4
months leaving her as the sole provider. They
are still working to recover from that incident.

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?
Pt has hypertension and diabetes so he follows a
low sodium, low sugar diet to the best of his
ability
What are your food likes and dislikes?
Pt doesnt like onions, squash, pears, nectarines,
cherries. He loves asparagus, green beans,
bananas, watermelon and a good salad. His
favorite meal he has to eat in moderation.

Do you have any especially strong cravings?

How often do you eat fast food?

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?
In the past 12 months have you:
Experienced any changes in weight?

Had a change in your appetite?

Had a change in your diet?
Experienced nausea, vomiting, or diarrhea from
your diet?
Changed your diet because of difficulty in feeding
yourself, eating, chewing, or swallowing?

because it is chicken and dumplings.

Pt reports that he loves iced coffee from Dunkin
Donuts and has one daily.
Pt tries to avoid this but with being a trucker
sometimes this is the only option. He tries to get
the healthier options. He eats this about once a
week.
Pt tries to pack food in a cooler for work but
sleeps at truck stop when he is working. He eats
at various truck stop restaurants while on the
road. He and his family occasionally go out to
eat. On average when he is home it is 12x/month.
Pt went through financial strain when he was
unemployed but now can afford fresh fruits,
vegetables and meats.
Pt shops at grocery store, meat market, farmers
markets and orchards. He uses a cooler with ice
when he is on the road for work. He has a small
chest freezer at home and the regular
refrigerator/freezer. He loves to use grill when
the weather allows. They try not to eat fried
foods and preferred baked. They make crock pot
meals that you can freeze and reheat.
When pt is working he eats alone but when he is
home they eat as a family.
Pt takes a daily OTC multivitamin supplement.

Pt is trying to lose weight to become a diet

controlled diabetic and to help with his
hypertension. He has lost 10 pounds since
January.
Pt reports no change in appetite.
Pt reports that he is trying to make healthier
choices and drinking more water.
Pt denies nausea, vomiting and/or diarrhea.
Pt reports no issues with feeding or ADLs.

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

0530 6/14

Iced Coffee with

cream only
Sausage and Egg
Croissant
Banana

Large

Brewed coffee

Dunkin Donuts

1 sandwich

Baked

Dunkin Donuts

None-fresh fruit

1300

Grilled Chicken
Salad wrap

1 wrap

Bought at store
and ate in work
truck
Deli at Pilot truck
stop

1300
1800

Diet Coke
Glucerna bar

Large
1 snack bar

2030

Baked chicken,
steamed broccoli,
mashed potatoes
and gravy

2030

Diet Coke

baked chicken
with skin, 1
serving of
broccoli (1/2 cup
or so), 1 serving
of mashed
potatoes (about
1/2 cup), 1
serving of brown
gravy (about 3-4
tablespoons)
2 cups

Grilled Chicken,
light Caesar
dressing, romaine
lettuce
Fountain soda
Deli at Pilot stop
Prepared/processed Bought at store
and had in work
truck
Baked chicken,
Diner at TA truck
boiled potatoes
stop
with milk, steamed
broccoli, canned
gravy

2100

Coffee with
cream only
Iced Coffee with
cream only
Multigrain bagel
and cream cheese

0530
0800

0645 6/15
0645

1 cup

Fountain soda with

meal
Brewed coffee

Large

Brewed coffee

Diner at TA truck
stop
Diner at TA truck
stop
Dunkin Donuts

1 bagel, 1
Philadelphia pack
of cream cheese

Toasted

Dunkin Donuts

Health maintenance (must address sleep, exercise, stress management):

Sleep pattern:
Pt tries to maintain schedule but finds its hard to
keep a 9-5 schedule with being a trucker. He
sometimes has to sleep all day to drive at night
and then has times where he drives all day to
stop after 11pm. He does try to get a minimum
of 6 hours of sleep. He has a required 10 hour
stop time daily where he cant drive. This is at
the end of day and he uses time to eat, shower
and sleep. When the pt is home he is able to
keep a more regular schedule.

Exercise:

Stress management:

Pt exercises at gym when he is home on

weekend. He walks at truck stop when he has
chance typically twice a week. He has small set
of weights he keeps in his truck. If he is stopped
at a truck stop that has a gym (treadmill, bike,
stepper) he uses them. He finds it hard to
exercise on the road but tries to keep moving.
Pt has gotten better about not holding in stress.
He talks to his family. He counts to 10 and does
deep breathing exercises. Pt has found that
walking helps clear his mind and reduce stress.

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:
Pt feels that he is in decent health. He is working to improve his health by changing his eating habits
and trying to exercise more. Pt feels that his energy level has improved since he began eating healthier.
He had no complaints of fever, chills or night sweats.
Skin:
Pt doesnt use sunscreen as often as he should. He has gotten sun poison in the past from burns. He
reports no issues with his skin. There are no growths that have changed. He states he only has dry skin
during the winter.
Hair:
Pt states that he has always had a dry scalp that gets worse in the winter. He takes hotter showers
during the colder months which he believes irritates it. He uses a moisturizing anti-dandruff shampoo.
Pt has noticed that his hair is beginning to thin and he is getting a bald spot. His father went bald at an
early age.
Nails:
Pt states that he bites his nails and has done so since he was a child. He keeps them short to try and
break the habit.
Eyes:
Pt wears sunglasses when driving. He states that he occasionally needs reading glasses but isnt sure
what the strength is. His had blurred vision when he was initially diagnosed with DM-2.
Ears:
Pt has no hearing deficit that he is aware of. He uses q-tips to clean his ears daily to every other day. He
has driven trucks for over 30 years and states that they are very loud.
Nose and sinuses:

Pt reports seasonal allergies during spring and fall which cause sneezing and post nasal drip. He gets a
cold once a year.
Mouth:
Pt reports that he was never taught good dental habits as a child. As a result he had many cavities as a
child. He brushes once a day and uses mouth wash in the evening.
Throat and neck:
Pt had his tonsils removed as a child and that resolved many of his sore throat issues. He states he gets
hoarseness if he is tired or has been talking for extended periods. He reports no pain or stiffness in his
neck.
Breasts and axilla:
Pt reports no problems with breasts or armpits. No rash, discharge or tenderness.
Respiratory:
Pt reports sneezing and coughing when his allergies flair up. He had bronchitis for the first time in
December 2013. He only experiences shortness of breath if he tries to overexert himself during
exercise. Pt said it resolves within a few minutes of resting.
Cardiac:
Pt reports that he had EKG with primary care provider last year which was WNL. He reports no issues
with chest pain, edema, dizziness or heart disease.
Peripheral vasculature:
Pt has hypertension. He states he does not have issues with circulation or varicose veins. He
occasionally gets leg cramps when he has been driving for hours without a break. Once he takes a break
and walks around the cramps resolve.
Gastrointestinal:
Pt reports that he has a bowel movement daily. He has a history of hemorrhoids. Pt reports no
unplanned changes in appetite. He is watching what he eats. Pt denies nausea, vomiting and diarrhea.
Pt has not has and GI workup in recent years.
Urinary:
Pt denies any urinary issues. He has no issues urgency, pain or incontinence. Pt states that he does
urinate more frequently since being diagnosed with DM-2 but he drinks more water now. He has
discussed this with his primary care provider and has been worked up for the issue. All tests came back
normal.
Musculoskeletal:
Pt reports soreness after working out if he overdoes it. He denies any swelling, stiffness, back issues. He
has never had any sprains or broken bones.

Neurological:
Pt reports sinus headaches particularly during the summer months. He denies any weakness, numbness
or tingling. He denies any syncope or seizures.
Psychological:
Pt believes that he had ADHD as a child that has improved. He states he had difficulty sitting still and
focusing on tasks. He states no problems with anxiety or depression.
Male or female reproductive:
Pt reports using condoms. He has been sexually active since he was 18. He reports an inguinal hernia
that he has had for 10 years. He plans on getting it repaired this year. He does not perform monthly
self-exams. He has not had any change in libido since being diagnosed with hypertension and DM-2.
OK to defer nutrition, as this is addressed in depth elsewhere
Endocrine:
Pt states that he has DM-2. He was initially tired and thirsty before he was diagnosed. These symptoms
have resolved.
Lymph nodes:
Pt reports no tenderness of neck or underarms.
Hematological:
Pt reports never having a blood transfusion. He states he has no issues with bleeding or anemia. His
blood type is O positive.
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:
Pt is 53 years old and looks to be about 50 years old. He does have an obese abdomen. He is weight
bearing and appears to have no issues with his gait. His is well groomed and clean dressed. His speech
is clear and there are no signs of distress.
Measurements:
Pt is 511 and weighs 211 pounds today. His vital signs are BP 140/96 in right arm and 142/96 in left
arm, P70, T98.7 R14. Pulses are regular and equal.
Skin:
Pt skin appears normal. Skin is a natural color. He does have some peeling sunburn across the bridge of
nose. No signs of bleeding or bruising. His skin is slightly moist. He does have callousing on hands. Pt
not exhibiting signs of tenderness. No sign of edema, skin does not appear taut or tented. The patient
has a few skin tags on right side of neck.
Head and face:

Pt does not have any lesions to face or scalp. Pt has thinning hair with balding occurring to top of head;
this appears to be normal aging as hair looks healthy. Hair is not greasy. Pt has CRT <3 seconds. Pt nails
are short. They do not appear to be brittle. Pt has no facial drooping. Pt can smile, frown, raise
eyebrows, puff cheeks, and whistle. All nerves appear to be intact. Pt has equal and regular temporal
pulses. Pt able to clench jaw, open and move side to side. Pt did not experience discomfort with exam.
Eyes:
Pt passes color blind testing. PERRLA. Pt has no redness, irritation or discoloration to eyes. Pt can
follow finger in all directions. No thinning or eyes lashes or eyebrows.
Ears:
Pt passes whisper test. No discharge from ears. Pt ears appear normal. Pt ears are natural skin color.
No redness or lesions.
Nose and sinuses:
Pt nose is symmetrical. Both nostrils are patent. There is no redness or discharge. No swelling near
eyes or nose. No pain with frontal and maxillary sinus palpation. Pt sense of smell is normal. Can
distinguish between coffee and oranges.
Mouth and throat:
Pt lips moist. Oral mucosa is moist. Pt tongue is midline and can stick out tongue. No lesions present. Pt
missing a few teeth. Gums are red/pink, appear moist. No signs of bleeding. Uvula midline. No edema
present.
Neck:
Pt does not appear to have difficulty breathing. Full ROM. Pt can shrug shoulders. Trachea is midline.
No palpable masses. Pt has 3 small skin tags on right side of neck. Thyroid tissue moves with
swallowing. No palpable lymph nodes.
Upper extremities:
Nails are short, do not appear brittle. CRT <3 seconds. Skin color normal. Absence of clubbing. Pt had
equal strength in hands. Pt can raise both arms equally. No pain during ROM or palpation. Pt has no
numbness or tingling. Pt can tell which side is being touched. Pt has equal and regular pulses.
Back, posterior, lateral thorax:
Pt does not appear to have abnormalities of the spine. Shoulders are symmetrical. No pain with ROM.
Anterior thorax:
Chest wall symmetrical. No accessory muscle used for respirations. Pt does not have bulging veins.
Heart (note that the exam is divided between p. 1039-1040. Include all info in this section):
Normal heart sounds, no evidence of murmur. No pulsations seen or heard. Pt apical pulse is 72.
Breasts:

Pt skin color is normal. No edema. No masses or lesions present. No discharge noted. Breasts are
symmetrical.
Jugular veins:
No JVD noted.
Abdomen/Gastrointestinal:
Pt abdomen obese, non-tender. Skin is normal color. Pt has scar consistent with appendectomy. Bowel
sounds present in all four quadrants. No pain during palpation. No bruits or rubs heard.
Inguinal area:
Femoral pulses present. No lymph nodes palpable. No evidence of pain. Pt requested that inspection
not be done.
Lower extremities:
Skin normal color. No edema. CRTs <3 seconds. No evidence of varicose veins. Skin appears dry but
healthy. No evidence of flaking. Pt has strong popliteal and dorsalis pedis pulses. Pt has full ROM in
hips, knees, ankles and feet. No pain or discomfort noted. Pt had good muscle tone. No decreased
sensation noted. Pt able to distinguish postion. No clonus.
Neurological system (note that the exam is divided between p. 1036 and two sections on p. 1041.
Include all info in this section):
Pt appears bright, alert and relaxed. Pt is clean and well groomed. Facial expressions symmetrical. No
issues with speech or comprehension. GCS of 15. Pt able to perform serial 7s with no difficulty. Pt able
to state birthday, name of president, significant others birthday. Pt able to use good judgment during
scenario questions. Pt understands realistic awareness of health status. Pt can draw a shape and face of
clock with no difficulty. Pt can identify sounds and distinguish between left and right side of the body.
Pt can count by 3s backwards from 100. Pt understands and can explain the meaning of Dont count
your chickens before they hatch. Pt has logical coherent and goal oriented thought processes. Pt
denies any suicidal ideations. Pt able to sense light touch. Pt can distinguish from sharp and dull
objects. Pt can tell hot from cold and where it is felt. Pt can identify position changes. Pt can sense
vibration on wrists and ankles. Pt able to identify a pen, coin and key by manipulating them in hand. Pt
can distinguish letters being written on hand. Pt able to distinguish two objects touching hand at 5mm.
Pt can feel both cotton tips touching face on opposite sides. Pt olfactory nerve was tested during nose
and sinus assessment and is normal. Pt CN V was tested during neck assessment and with sensory
testing and is normal. CN VI tested during eye assessment and is normal. CN VII tested already and is
normal. CN VIII tested during ear exam and is normal. CN IX and X tested during mouth exam and appear
normal. CN XI tested during extremity exam and is normal. CN XII tested and pt speech is clear. Pt
shows no signs of pronator drift. Pt has steady gait. Pt able to touch nose to finger without difficulty. Pt
can make a figure 8 with foot in air without difficulty. Pt can touch thumb to all fingers. Pt has normal
DTRs. Brachioradialis flexes, biceps flexes, patella extends. Pt flexes toes and shows normal plantar
reflex. No Babinksi reflex is noted. Pt performs tandem walk without difficulty.
Genitalia/anus/rectum/prostate:
Exam 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):
Readiness for enhanced self-care management related to personal health as evidence by patient stating
the need to live a healthier lifestyle, patient taking a more active role in healthcare, and patient actively
creating a diet and exercise plan.
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?):
Pt will continue to keep a record of food like we did with the 24 hour recall. He has downloaded an app
for his phone that will allow him to enter foods and see the calories and nutritional status. He would
like to weigh to weigh 180 pounds. He plans to reduce his caloric intake over time. He will start with
1800 calories/day and then work his way to 1500 calories/day. Pt plans to walk for 30 minutes each day.
This might not be the same time each day but he will walk at the truck stops and when he is on home
time. When he is home he plans to go to the gym and lift weights and use the equipment there. He will
measure his weight every Sunday morning and enter it into his diet app. He has set a goal of a year so
that he can slowly lose weight and keep it off. I will track the patient and meet once a month to
reevaluate this goal to see if it is still an appropriate goal.
Nursing intervention r/t patient goal #1 (what will you do to help/support them?):
Provide support and actively listen to patient and their goals. I can assist the patient in the journey for
improvement by continuing to follow them and act as a support person. I can also provide resources
that they may need to succeed.
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):
Deficient knowledge on dangers of hernia related to lack of interest in learning, unfamiliarity with
resources, and misinterpretation of current information.
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?):
Pt has stated that he knows that he needs his hernia repaired. He has health insurance now which was a
problem in the past. Pt has set up a visit to his primary care provider to have a yearly exam. He will get
the referral for a general surgeon at that time. Pt plans to meet with both by August 2014. He will
begin his class teaching on the dangers of hernias and how to prevent them July 2, 2014. He will have
his surgery by September of 2014. Pt plans to follow up with primary care doctor to ensure that he gets
the procedure done this year. He has noticed that it is becoming more difficult to pass his DOT physical.
He relies on this to make a living, therefore patient need the surgical repair.
Nursing intervention r/t patient goal #2 (what will you do to help/support them?):
I will provide support to the patient and assist with learning. I can help the patient assess the resources
that he has found. Sometimes learning about a procedure can be overwhelming and intimidating.
Having a strong support team that you can talk to and ask questions can be helpful.