report –Update | 100% Correct.
Sentinel U: Amanda Camden:
Client Information Name Age Amanda Camden 52yo Race/Ethnicity
Language(s) White English Sex Assigned at Birth Gender Identity Pronouns
Female Female She/Her/Hers Height Weight Marital Status 5’ 4” / 163 cm
140 lb / 63.5 kg Married Allergies Penicillin (Rash) Chief Complaint Annual
Female Wellness
Health History:
Health History Past Visit Reasons Migraine (6 months ago) Palpitations (1
year ago) Past Medical History Migraine Hot flashes Left knee torn
meniscus Premature ventricular complexes Past Surgical History Two C-
sections Left knee arthroscopy for torn meniscus Home Medications
Ibuprofen 600 mg po every eight hours as needed for headaches
Magnesium (OTC) 400 mg po daily Daily multivitamin one capsule daily
Ubrogepant 100 mg tablet take once and may repeat once after two hours,
do not exceed 200 mg daily Family History HTN (Father, Mother) Type 2
non-insulin dependent diabetes mellitus (Maternal Grandfather) HLD
(Mother) Immunizations Shingles vaccine (6 months ago) Influenza vaccine
(9 months) COVID vaccine booster (1 year ago) Social History Smoking
Status: One pack a day for 20 years (Quit 14 years ago) Smokeless Tobacco:
Denies Alcohol Use: Wine (1 glass/5 oz) 1-2 times a week Drug Use: Denies
Current Diet: Low sodium How Often do you Exercise: 3x/week Type
Exercise: Outdoor walking Wears Seatbelt: Yes Sexually Active: Yes How
Many Sexual Partners: 1 How Many Partners in Lifespan: 3 How Long with
Current Partner: 15 years Contraception: No History of STIs: Denies Feels
Safe at Home: Yes Health Maintenance Last Annual Exam: 1 year ago Last
Pap Smear: 1 year ago Last Pap Smear Results: Normal Last Mammogram:
1 year ago Last Mammogram Results: Negative Last Hemoccult Stool
Screening: 1 year ago Last Colonoscopy: None Last Prostate-Specific
Antigen (PSA): N/A Last Bone Density Test: No prior testing Vision
Problems: Yes, corrected with glasses Wears Contacts or Glasses: Reading
glasses Last Eye Exam: 1 year ago Dentist Every Six Months: Yes Has
Trouble Hearing: No Brushes/Flosses Daily: Yes. Health History Social
Determants of Health Financial Resource Strain: Currently unemployed
Transportation Needs: Shares a car with her husband Housing Instability:
Denies Food Insecurity: Denies Literacy: Bachelor of Science in Nursing
VITALS:
SPO2 97% ROOM AIR
,NUMERICAL PAIN: 0/10
RESPIRATORY RATE: 12
TEMPERATURE: 98.3 F
BLOOD PRESSURE: 120/88
HEART RATE: 88 BPM
Which area of information or vital signs if TOP priority, out of the
following options? AGE, GENDER, RACE/ETHNICITY, WEIGHT.
Answer: GENDER.
Got wrong, thought it was age. because Age most directly drives preventive
screening recommendations, risk stratification, and clinical decision-making
—especially in a 52-year-old female wellness visit. Gender is important, but
is already established and stable for this visit.
Inquiry:
What brings you in today? I am just here for my wellness exam.
Do you have any specific concerns related to the wellness exam? No, I am old hat at
this now.
Tell me about your history: I have migraine headaches and hot flashes. I tore the
meniscus in my left knee, and I have PVCs
Chief Complaint (CC)
Here for wellness exam.
History of Present Illness (HPI)
No specific concerned for the welnness exam.
Past Medical History (PMH)
Medical History: Migraine headaches, hot flashes. Tore meniscus in Left knee. Has hx;
of PVC's. Patient has not followed up with neurology.
Past Surgical History (PSH)
Past surgical history: 2 c-sections. Left knee arthroscopy for torn meniscus.
Medications
Medications: ibuprofen 600mg as needed, magnesium 400mg daily, a multivitamin one
capsule daily, & new migraine medication. Allergy:
penicillin, reaction is a rash.
Health Practices/Preventative Health
, Holistic wellness practices: Chamomile tea at night to help with relaxation and sleep.
Immunizations: Shingles shot 6 months ago, COVID vaccine booster one year ago, and
influenza vaccine 9 months ago. Last annual exam was 1 year ago. Last pap was 1
year ago. Last mammogram was 1 year ago. Has not had a colonoscopy, but had a
stool blood screen a year ago. Last eye exam 1 year ago, received new glasses
prescription
Family Medical History (FMH)
Family Medical History: Mother has HTN and hyperlipidemia. Father has HTN.
Grandfather had Type 2 non-insulin dependent diabetes.
Psychosocial Habits
Psychosocial Habits: No smoking stopped smoking 14 years ago. Alcohol used, drinks
a glass of wine a couple times a week. Recreational drugs not currently used but used
some in high school. Patient is sexually active, and only with her husband. Birth control:
husband had a vasectomy after their second son. Work: Home health company went
bankrupt, pt picking up PRN shifts until she can find something full time. Stress
management: wine and cuddling with cats and dogs. Living situation: big home, wants
to sell & get something smaller. Exercise habits: Walking 3x a week. Eating habits:
foods low in sodium because HTN runs in family. Sleep habits: waking up 2-3x night
drenched in sweat, takes an hour to cool off and go back to sleep. Pt state she is
always tired and hasn’t gotten a lot of sleep lately.
Which area of inquiry, excluding cc or HPI, is TOP priority, out of the following
options. Past medical history, family medical history, psychosocial habits, health
practices/preventative health
Answer: Psychosocial habits. (because complaints of sleep pattern disturbances
associated with hot flashes should be investigated)
Answer I chose was: health practices/preventative health because of the overdue
colorectal cancer screening, need to assess age-appropriate screening adherence. I
also used the “open evidence” resource that was instructed to use and there was
emphasis onf screening usage for perimenopausal woman.
Review Of Systems:
Constitutional
Denies complaints of fatigue or unexpected weight gain/loss.
Eyes
Denies eye pain or blurred vision, positive for prescription reading glasses.