Comprehensive Assessment Tina Jones | latest updated 2022 | 10 pages

Introduction An annual physical assessment is important in keeping one healthy. At this visit the patient can establish care with a provider and be evaluated. By having an initial assessment completed the provider has something to compare the individual’s other visits to. This helps the provider to see when changes arise and properly diagnose health issues. Tina Jones is about to begin her new job at an accounting firm. She presents to the clinic for a comprehensive assessment. The purpose of this assessment is to create a relationship with Ms. Jones and obtain her baseline health and well-being. Subjective Data & Reliability Ms. Jones is a 28-year-old, single, African American female. She attends First Baptist church weekly as well as bible study on Wednesdays. Ms. Jones just graduated with her Bachelor’s degree in accounting and is starting an accounting job at Smith, Steven, Stewart, Silver & Company in two weeks. She is presenting to the clinic today for a pre-employment physical. Ms. Jones is offering her information freely and is a reliable historian. General Survey Ms. Jones is alert and oriented. She appears in good spirits and is seated upright on the exam table. She is well-nourished and well-developed. She is dressed appropriately and displays good hygiene COMPREHENSIVE ASSESSMENT 3 Reason for Visit Ms. Jones presents to the clinic for a pre-employment physical prior to starting her job. History of Present Illness Ms. Jones is at the clinic due to being "required to have a recent physical exam for the health insurance at my new job." Ms. Jones feels healthy and admits having started taking care of herself better than in the past. Medications Fluticasone propionate, 110 mcg 2 puffs BID. Albuterol 90 mcg/spray MDI 2 puffs Q4H prn. Metformin, 850 mg PO BID. Drospirenone and ethinyl estradiol PO QD. Allergies Ms. Jones has an allergy to penicillin, causing hives, that required hospitalization when she was young. Being around cat’s give Ms. Jones itchy and watery eyes. She tries to be around them as little as possible.