Comprehensive history and physical worksheet

Your name:
Ruby Sabina

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):
Physical/Follow up umbilical hernia

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:
Umbilical hernia: presented March 2015. Location: at the umbilicus. No pain noted. Radiation: Has not
moved from original location. No change in feeling from baseline. Quality: Pain is a 0/10 rated by
patient. Associated manifestations: Patient has experienced some ease of bowel movement when
hernia is pushed. Aggravating factor: Hernia appears to be more prominent when patient is full or has a
lot of gas. Alleviated with bowel movement or relief of gas. Occurs in all settings. Timing: First occurred
in March of 2015. Is continuous at all times. Meaning: Has not altered lifestyle at all, but does have some
anxiety about what could happen with hernia in the future.

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: Chicken pox- 1949
Chronic illnesses or diseases: none
Injuries/prior accidents: none
Special needs: none
Prior surgeries: knee replacement 2/2014, hip replacement 6/2014

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:
Food allergies: patient states no known food allergies
Drug allergies: patient states no known drug allergies
Environmental allergies: patient states no known environmental allergies

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
Daily aspirin 81mg Daily Prevention of 10+ years
stroke
Multivitamin Daily Preventative 10+ years
health measure
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 None None None during life, Deceased: 60
deceased due to years old at time
cardiac event of death due to
cardiac event
Father None None High blood Deceased: 55 yo,
pressure, death cardiac event
due to cardiac
event
Sibling None None None Current age: 81
YO
Sibling None None High blood Current age: 80
pressure YO
Child None None None Current Age: 60
YO
Child None None None Current age: 58
YO
Child None None High blood Current age: 56
pressure YO
Sibling None None None Deceased: 70 YO,
liver failure
Sibling None None None Current Age: 85
YO
Sibling Breast CA: 76YO, None None Current Age:
completed 77YO
treatment last
year
Child None None None Current age: 35
YO
Child None None None Current age: 32
YO
Child None None None Current age: 30
YO
Child None None None Current age: 20
YO
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 Yes. I have at A My kids used G Yes, there E No. I do not
(review p. 59 of several times in to annoy me all have been times I drink in the
your text and my life felt the the time, bugging have felt guilty morning
complete the four need to cut back me to stop about alcohol
sections to the on alcohol drinking. consumption
right):
Tobacco use: Previous smoker. Quit in Type: Cigarettes Amount: 1PPD Length of use:
1996 after smoking for 31 years. 31 years

Drug use: None Type: NA Amount: NA Length of use:

NA

Presence/absence domestic violence? None

Sexual orientation? Heterosexual
Birth control? None Number of partners? Current:1
Type of employment Education Level Socioeconomic Status

Self Employed: retired from Some college Well off, no issues

owning small business

Spiritual assessment FICA (see p. 184 of your text for complete listing of questions):
Faith and Belief:
Do you consider yourself spiritual or religious? Absolutely not

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 and wife

Importance:
What importance does your faith or belief have None
in your life?
 Have your beliefs influenced how you take care No
of your health?

What role do your beliefs have in regaining or None

maintaining your health?

Community:
Are you part of a spiritual or No
religious community?

Does this group support you? N/A

How?

Is there a group of people you N/A

really love or who are important
to you?

Address:
How would you like the healthcare team to I would like to live as long as possible, so
address these issues in your healthcare? whatever I need to do to maintain a healthy
lifestyle would be helpful

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 Washington, DC for 78 years. My
in_____? entire life

Where are you from originally/where were you I was born here in the district
born?

With which ethnic group do you identify? How I consider myself an American first, but my mom
strongly? was Irish and my father was Scottish.

Where have you lived and when? Did you have I lived in Viet Nam for several years in the 70s.
health problems or exposures in any of those My health was excellent at the time and I dont
places? How did you recover? think I even saw a doctor while I was there.

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?
I value the future most of all. I believe human
beings are pretty good. I believe we are all here
to help each other. I retired to farm so I think
nature is important.
 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?
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?
No
My family is the most important to me. I believe
education is important if you need it to do what
you want to do. Now that I am retired I enjoy
being outside.
Being healthy means living longer and being with
those I love.
Eating well, maintaining a good exercise regimen.
Visiting my PCP on a regular basis.
I get a lot of physicial exercise every day by
farming and gardening outside. I also walk my
dog frequently. I eat a healthy diet.
Being ill or sick constantly is usually the beginning
of the end. Most people in my family stay healthy
till they die.
Genetics and lifestyle
I try to take it easy for a few days and not have a
lot of beers. Rest as much as possible.
My primary care provider is who I visit if I am
sick. She is very helpful.
My wife generally tells me if I need to go to the
doctors. She is who I want to be with if I do not
feel well.
My wife is the most important person when it
comes to maintaining my health and making
health decisions.
I think mental illness is an excuse people use to
not confront their problems. My brother is
handicapped, but physicially and I try to help him
as much as I can. I dont have specific thoughts
about dying, but I would not like to be in a lot of
pain.
None
 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?
What are your familys goals for the health and
well-being of the whole family? What are your
I have no preferences as long as they are
competent
English
No
No
No
No
I am the patriarch, my wife is the matriarch. I
have 5 siblings, 1 of whom is dead. I also have 7
children. 6 of them are married. Their husbands
and children are also a part of our family. I have a
lot of grandkids.
American
5 of my 7 children are near me. I do not see my
siblings very often anymore except for my
brother David who comes to dinner once a week.
I see my kids on a weekly basis.
My children are grown, so they no longer live
with me. They occasionally ask my wife and I to
babysit, but not too much. I feel happy with this.
We celebrate birthdays ALL the time. We also
celebrate Christmas and thanksgiving. We try to
get together at least once a month, but birthdays
are the most important. When someone has a
birthday we blindfold them and take them
somewhere for a surprise.
I hope to live a long time and see my
grandchildren grow up. I think my family wants to
 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?
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?
see me grow much older. I work toward these by
staying as healthy as I can.
Continue to monitor my health as needed. I
worry about blood pressure and my hernia
needing something emergently.
My family is not a part of any social group. We
are our own social group.
My children all had Christian weddings and they
celebrate their anniversaries, as do my wife and I.
I have tons of grandkids and love celebrating
them as well! Most of my daughters chose to
breastfeed if possible, but 1 did not. We really
celebrate most things in a pretty normal way.
Most of my kids are successful and have good
jobs. One of my grandsons died 8 years ago, this
took a big toll on one of my sons but he seems to
be doing okay now. One of my daughters is in
school and working. My last child to go to college
is in the Coast Guard. For the most part they are
pretty happy healthy kids, and we are a good
family.
I eat a normal diet.
None.
I like salty foods.
2 or 3 times a month
4 times per month
Yes
We grow a lot of veggies in our garden. We go to
the grocery store or farmers market. We have a
refrigerator. My wife and I both cook.
I eat with my wife
No
 In the past 12 months have you:
Experienced any changes in weight? I have lost weight, about 30 pounds in one year

Had a change in your appetite? No

Had a change in your diet? I do not snack as often now that my wife and I
both retired
Experienced nausea, vomiting, or diarrhea from No
your diet?
Changed your diet because of difficulty in feeding No
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
7am Toast with 2 pieces, 2 Toaster Dining room
vegemite, coffee tablespoons
2pm Chicken with pita, 1 breast, 1 pita, 1 Self, baking Dining room
cucumber and cup cucumber chicken
tomatoes and tomato
6pm Shepherds pie 3 cups My wife made Dining room
this
Throughout day Water 8 glasses Tap
8pm Beer 4 cans Outside on deck

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

Sleep pattern: I go to bed at 10pm and wake up around 5am. I
sometimes wake once to use the bathroom
Exercise: I work outside on our farm all day, I walk the dog
often, physical labor
Stress management: Relaxing, having a beer

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:
I feel like I have lost a lot of weight, but generally feel like I have a lot of energy for my age.

Skin:
I have a lot of moles, but none that are new. I spend a lot of time outside and do not wear sunscreen.
My skin seems very saggy, but I think this is because I am old

Hair:
My hair has been salty for as long as I can remember

Nails:
My toenails are very thick. My fingernails are fine.

Eyes:
I use reading glasses as I have for many years. Otherwise my vision is fine.

Ears:
I have pretty good hearing. I sometimes ask my wife to repeat herself but otherwise nothing special.

Nose and sinuses:

My sinuses seem to be okay. I think I seemed to be slightly affected by pollen this year, which is different
for me.

Mouth:
Nothing to note. My teeth are in ok shape.

Throat and neck:

Saggy skin on my neck, but nothing special

Breasts and axilla:

None. Patient does not perform breast examination.

Respiratory:
No respiratory issues ever in my whole life

Cardiac:
I worry about having high blood pressure because of my parents, but I have not noticed anything
significant or been told about anything

Peripheral vasculature:
None

Gastrointestinal:
I lost a lot of weight in the last year, but I think it is because I am doing a lot more work outside and
snacking less. I am worried about this umbilical hernia, but it has not changed at all since I first noticed
it. When I push it I have to use the bathroom.

Urinary:
Somewhat frequent urination, but nothing unmanageable

Musculoskeletal:
Joints do not move as fast as they once did. But my knee and hip work great

Neurological:
I feel somewhat forgetful. I also hit my head when I fell at night once last year.

Psychological:
None

Male or female reproductive:

No changes. My wife and I do not frequently have sex anymore but when we did I took Viagra.

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

Endocrine:
Lost weight in the last year according to patient. No other endocrine information

Lymph nodes:
No enlargement or tenderness

Hematological:
No bruises or bleeding out of the ordinary. Never had a blood transfusion

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:
Patient appears to be stated age, 78 years old. Appears to be generally slender. Good posture. Normal
odor and good hygiene. Gait is appropriate, steady. Dressed in casual clothing, has some paints on shirt.
Appears in good mood. Speech is normal, no slurring. Expressions equal. No distress or pain noted.

Measurements:
Patient is 57. 160 pounds. Temp 36.8. Radial pulse: 72. Respirations 16. Blood pressures: 118/60,
118/64

Skin:
Caucasian skin color. No bruises or bleeding noted. Some vascularity noted in upper arms. Moles noted
all over body. None immediately seen with odd discolorations or odd shape. No diaphoresis noted.
Warm. Smooth texture. Skin turgor is lacking, but appropriate for age. No edema.

Head and face:

Head shape appears to be normocephalic and symmetrical. No bumps or lesions noted upon inspection.
Hair distribution is excellent for age. Color is black and white. No bumps noted under hair. Face
symmetrical and oval shaped. Eyes symmetrical. Smile symmetrical. Forehead wrinkles when smiling.
Patient is able to puff cheeks, purse lips, whistle, and show teeth appropriately. Temporal pulses
normal. Manidibular joints feel normal, no discomfort with movement or clicking. Scalp is shiny, no
lesions or masses.

Eyes:
Near vision seems somewhat off, as patient stated. Distance vision fully intact. Colors identified
appropriately. Corneal reflexes are WNL. Eyelids are somewhat saggy, normal for age, symmetrical. Eye
position is normal. Eye color is normal. No redness noted in conjunctiva. No redness, enlargement, or
swelling of the lacrimal apparatus. Eyes move smoothly and symmetrically. Sclera is white with some
small vessels noted. Corneal surface is shiny. Pupils are 4mm and constrict briskly.

Ears:
Ear appears normal upon inspection and palpation. Hearing is normal, excellent for age. Patient passed
voice whisper test, able to repeat words whispered from 2 feet away. Sound lateralized in both ears
during weber test. Positive Rinne test. Ear matches flesh of the rest of the body. No pain or tenderness
when palpated. No redness, swelling, or tenderness in the ear canal.

Nose and sinuses:

Nose appears symmetrical in the midline of the face. No swelling or bleeding. No nose bleeds reported.
Each nostril is patent. No discharge noted. No swelling around the nose and eyes. No discomfort during
palpation around the nose and eyes.

Mouth and throat:

Breath smells fresh. Lips and membranes are pink with no evidence of lesions. Tongue is in the midline
of the mouth. The tongue is pink, moist, and rough from taste buds. Tongue is strong and symmetrical in
strength. Pink mucosa inside of mouth. Gums are pale red, some whiteness noted in places. All 32 teeth
are present, with 7 filled cavities noted towards the back of each side. Palates are pink and ridged. Uvula
of the throat rises when patient makes noise. Throat is pink and has no swelling or exudate or lesions.
Gag reflex is present.

Neck:
Neck muscles symmetrical. No enlargement or masses of thyroid noted. Patient is able to move head
with a full range of motion. Adams apple is noted.

Upper extremities:
Joints appear to be symmetric in structure. No swelling or wasting noted. Temperature normal. No
increased joint space. No tenderness. No pain when performing ROM. Strength is 5/5 on each side.

Back, posterior, lateral thorax:

Thorax is elliptical. Shoulders are the same height. No abnormal curvature of the spine noted.No
retractions or bulging. No accessory muscles are used to breathe. Respirations are 16 per minute,
regular and even. Lung sounds are clear. Sputum reported as normal.
Anterior thorax:
Thumbs separate normally during thoracic expansion of the anterior thorax. Resonant sound heard
during lung percussion.No fremitus.

Heart (note that the exam is divided between p. 1039-1040. Include all info in this section):
No pulsations of the aortic, pulmonic, midprecordial, mitral or tricuspid area are visible. No palpations,
thrills, or heaves are palpated as well. S1 and S2 are normal, with a slightly louder S2 noted. No ejection
click heard. No S3 or S4 are heard at this time. No murmur is noted at this time. No friction rub can be
auscultated. All cardiac landmarks have been auscultated.

Breasts:
Breasts are flesh colored. Areolar are slightly darker. Moles noted throughout. Symmetrical vascularity.
No thickening or edema. No inversion of the nipples. No flattening. No dimples. No masses or lesions.
No discharge. Lymph nodes are not palpable, no pain.

Jugular veins:
Jugular veins observed at 45 degree angle. No JVD noted. No JVP indicated.

Abdomen/Gastrointestinal:
Abdomen is rounded. Skin is taut across the abdomen. Abdomen is symmetric bilaterally. Uniform and
color, some red moles noted. No abdominal scars. No striae. No respiratory retractions. No peristalsis
movement seen. Pulsation is not visible. The umbilicus is protruding above the abdominal surface.
Opening can be felt through fascia. No pain noted when palpated. Bowel sounds are intermittent and
WNL in each quadrant. No bruits are noted or friction rub. Palpation is smooth and soft on each
abdominal quadrant. No guarding. Borders of the liver appear to be roughly 9 CM. Bladder is dull to
percussion. Bladder feels round. No tenderness in the kidneys. No tenderness in the liver. Spleen is not
palpable.

Inguinal area:
The inguinal area has no swelling or bulges. No masses were palpable at this time. No bowel is felt near
the scrotum.

Lower extremities:
Hip flexion is normal. Knees are in alignment bilaterally, no pain is noted, ROM is normal, scar noted on
R knee due to knee replacement. Toes and feet are normal shape. Angles have normal ROM. Toes point
forward and backward. Both feet are in alignment. No pain over the plantar fascia. No webbing of toes.

Neurological system (note that the exam is divided between p. 1036 and two sections on p. 1041.
Include all info in this section):
Facial expression is normal. Smiling when appropriate. Affect is calm. Patient is AOX4. Attention span
and memory appear to be in tact. Judgement, reasoning, processes appear to be normal. Spontaneous,
coherent speech is noted. GCS of 15. Can repeat numbers. Light touch can be felt on face, lower arms,
abdomen, feet, and legs and patient can accurately name location of stimulus. Can identify changes of
position. Vibration is felt on fingers and toes. Can identify objects when placed in hand. Can identify
touch at reasonable discrimination. Patient can identify when one stimulus is removed. Can identify
odors. Symmetry found on right and left sides of the face. No vertigo. Sensory components are in tact.
Speech is clear with no hoarseness. No downward drifting of one arm. Can alternate touching of finger
to nose. Balance is normal. All reflexes are in tact. Negative Babinski reflex.

Genitalia/anus/rectum/prostate:
Public hair is distributed normally. No lesions or inflammation noted. Skin is loose and wrinkled. Penis is
cylindrical in shape (no further examination per rubric)

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):
Imbalanced nutrition: less than body requirements related to increase in activity and decrease in caloric
intake as evidenced by loss of 30 pounds or more since last visit.

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 not lose any more weight before next visit.

Nursing intervention r/t patient goal #1 (what will you do to help/support them?):
RN will assist patient in finding foods that are high quality and calorie. RN will ensure adequate protein
by recommending high protein foods. RN will recommend ensure or other supplement.

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):
Risk for impaired skin integrity related to excess amount of time in sun with no protection

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 demonstrate knowledge of skin care and sun prevention by next appointment. Patient will
report use of sunscreen before next appointment. Patient will report no burns at next appointment.
Patient will see dermatologist for further evaluation of moles and skin by next appointment.

Nursing intervention r/t patient goal #2 (what will you do to help/support them?):
Provide information to patient about good skin care. RN will educate patient about the different types of
sun screen available, including lotions and different clothing. RN will help patient find dermatologist that
works with his insurance who can do further skin evaluation.