MSN 610 H & P Example-1.
Northern Kentucky University
MSN 610: Diagnostic Reasoning and Advanced Physical
Assessment
EXAMPLE
DEMOGRAPHICS Comprehensive History & Physical Exam
Providers Name: KJN, DNP Patient’s Initials: (Data Source) T.J.
Date of Exam: 12/25/2019 Patient’s DOB: 1/31/ 1988
Chief Complaint: Annual Wellness Visit Gender/Sexual Orientation: _M/ Heterosexual
History of Present Illness: Generally feeling well. Has had 2 “colds” , one in late fall an one last spring. He is
interested in the upcoming Flu season and wants “a flu shot” and wants to get established with a new PCP. His
previous PCP retired.
Past Medical History:
Active Problems: Hypertension, Asthma
Resolved Problems: Appendicitis
Previous Hospitalizations: Hospitalized at age 25 x 5 days with Acute Appendicitis @ St. Elsewhere Hospital
Surgical History: Circumcision at age 5
Appendectomy at age 25
Allergies: Lisinopril (ACEI)
Current Medications: Metoprolol succinate 25 mg PO daily
ProAir HFA ii puffs inhaled every 4-6 hours prn for bronchospasm
Flovent 100 mcg I puff inhaled every 12 hours
Social History:
Living Arrangements: Lives in a private 2 story home with his wife and 2 children.
Occupation: Mechanical Engineer
Environmental Safety: Works in his own private office. Drives his own vehicle to work and wears seat belts.
Denies workplace, violence, bullying or safety concerns. Denies exposure to toxic
Chemicals/gases.
Smoking: Smoked 1 ppd cigs x 5 years from age 20-25, but quit when he had appendectomy
Alcohol: Occasional 2-3 beers weekly
Drugs: Denies any illicit drug use currently. Did smoking marijuana as a
teenager. Other Non-Prescribed Drugs: Takes OTC cold/cough medicine when he
has a cold
This study source was downloaded by 100000848398116 from CourseHero.com on 06-27-2022 23:20:36 GMT -05:00
https://www.coursehero.com/file/57614511/MSN-610-H-P-Example-1docx/
, MSN 610 H & P Example-1.
Diet: Typically drinks coffee and cereal bar for breakfast. Fast food for lunch. Wife prepares meal at home for
dinner, usually well balanced to include fruits/vegetables. Tries to avoid carbs and sodas.
This study source was downloaded by 100000848398116 from CourseHero.com on 06-27-2022 23:20:36 GMT -05:00
https://www.coursehero.com/file/57614511/MSN-610-H-P-Example-1docx/
Northern Kentucky University
MSN 610: Diagnostic Reasoning and Advanced Physical
Assessment
EXAMPLE
DEMOGRAPHICS Comprehensive History & Physical Exam
Providers Name: KJN, DNP Patient’s Initials: (Data Source) T.J.
Date of Exam: 12/25/2019 Patient’s DOB: 1/31/ 1988
Chief Complaint: Annual Wellness Visit Gender/Sexual Orientation: _M/ Heterosexual
History of Present Illness: Generally feeling well. Has had 2 “colds” , one in late fall an one last spring. He is
interested in the upcoming Flu season and wants “a flu shot” and wants to get established with a new PCP. His
previous PCP retired.
Past Medical History:
Active Problems: Hypertension, Asthma
Resolved Problems: Appendicitis
Previous Hospitalizations: Hospitalized at age 25 x 5 days with Acute Appendicitis @ St. Elsewhere Hospital
Surgical History: Circumcision at age 5
Appendectomy at age 25
Allergies: Lisinopril (ACEI)
Current Medications: Metoprolol succinate 25 mg PO daily
ProAir HFA ii puffs inhaled every 4-6 hours prn for bronchospasm
Flovent 100 mcg I puff inhaled every 12 hours
Social History:
Living Arrangements: Lives in a private 2 story home with his wife and 2 children.
Occupation: Mechanical Engineer
Environmental Safety: Works in his own private office. Drives his own vehicle to work and wears seat belts.
Denies workplace, violence, bullying or safety concerns. Denies exposure to toxic
Chemicals/gases.
Smoking: Smoked 1 ppd cigs x 5 years from age 20-25, but quit when he had appendectomy
Alcohol: Occasional 2-3 beers weekly
Drugs: Denies any illicit drug use currently. Did smoking marijuana as a
teenager. Other Non-Prescribed Drugs: Takes OTC cold/cough medicine when he
has a cold
This study source was downloaded by 100000848398116 from CourseHero.com on 06-27-2022 23:20:36 GMT -05:00
https://www.coursehero.com/file/57614511/MSN-610-H-P-Example-1docx/
, MSN 610 H & P Example-1.
Diet: Typically drinks coffee and cereal bar for breakfast. Fast food for lunch. Wife prepares meal at home for
dinner, usually well balanced to include fruits/vegetables. Tries to avoid carbs and sodas.
This study source was downloaded by 100000848398116 from CourseHero.com on 06-27-2022 23:20:36 GMT -05:00
https://www.coursehero.com/file/57614511/MSN-610-H-P-Example-1docx/
