Chamberlain College of Nursing **We aren't endorsed by this school
NUR 426
Aug 4, 2023
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Immunizations: States her immunizations are current. She had the influenza vaccine this season and still got the flu. Fahm Grandparents (if known)/Parents/siblings/children Grandparents- states no known history Father is 70 years-old and still alive and well (70): heart disease, peptic ulcer disease Mother is 69 years-old and alive: breast cancer in remission; cholecystectomy for cholelithiasis TX Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships She reports that she drinks a glass of wine with dinner most nights; She denies any tobacco or recreational drug use Reproductive Hex Female: Age of menarche/menstruation cycle duration/gravida para status/Childbirth hex/sexual hex and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hex and concerns/issues with fertility (if any)/Testicular or prostate screening (if applicable) Screening for STI's (if applicable) Pertinent sexual history: Not sexually active and denies any sexual concerns Allergies (Food, Drug, Environmental, etc.) No known drug allergies List of Medications/supplements (prescription, OTC, complementary alternative therapies) Antacids as needed for "heartburn" Ibuprofen 400 mg three times daily as needed for knee pain Multivitamins Review of Systems: (ROS) Use this column to document the ROS below. General: Reports some weight loss, fever, night sweats, and difficulty sleeping HEENT: Denies headaches, changes in vision, From the ROS: list/highlight the current symptoms/complaints to generate a list of "reported or denied" symptoms below: Pertinent positive ROS : Reports some weight loss, fever, night sweats, and difficulty sleeping; RUQ abdominal that worsens with food and pain scale of 2- 3/10 and progresses to 6-7/10, 6/10. Anorexia, nausea and vomiting at onset.
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