Shadow Health Comprehensive Assessment Tina Jones -Documentation (Electronic Health Record) answered

4/25/2020 Week 4: Comprehensive Assessment | Completed | Shadow Health Week 4: Comprehensive Assessment Results | Completed Health Assessment - GCU - March 2020, nrs -434vn Return to Ass ignment (/assignments/321056/) Your Results Turn In (/assignment_attempts/6738271/choose Lab Pass (/assignment_attempts/6738271/lab_pass.p Overview Transcrip t Subjective Data Collection Documentation / Electronic Health Record Documentation Objective Data Collection Documentation Plan M y Exam Vitals Student Documentation Model Documentation Student Surve y Vitals B/P - 128/82mmHg HR - 78bpm RR - 15cpm T - 37.2c SpO2 - 99% weight - 185lb • Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP: • Pulse Ox: 99% • Temperature: 99.0 F Health History Student Documentation Model Documentation Identifying Data & Reliability Ms Tina, 28 year old African American, female, plesant, calm and co- operative. Patient is aware of her health and up to date on her care. Ms. Jones is a pleasant, 28 -year-old African American single wo who presents for a pre -employment physical. She is the primary source of the his tory. Ms. Jones offers information freely and wit contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey Patient looks healthy with no abnormality detected during inspection. Calm, not anxious, afebrile, anicteric, undertands and responds to questions appropriately. patient wears glasses for near sightedness. Ms. Jones is alert and oriented, seated upright on the examinatio table, and is in no app arent distress. She is well -nourished, well - developed, and dressed appropriately with good hygiene. Reason for Visit Patient is here for a complete health assessment for pre-employment physical. "I came in because I'm required to have a recent physical exam the health insurance at my new job." 4/25/2020 Week 4: Comprehensive Assessment | Completed | Shadow Health Student Documentation Model Documentation History of Present Illness She is diabetic and glucose is well controlled. Patient is also asthmatic and has PCOS Ms. Jones reports that she recently obtained employment at Smi Stevens, Stewart, Silver & Company. She needs to obtain a pre - employment physical prior to initiating employment. Today she d any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow H General Clinic. Ms. Jones states that the gynecologist diagnosed with polycystic ovarian syndrome and prescribed oral contracept at that visit, which she is tolerating well. She has type 2 diabetes which she is controlling with diet, exercise, and metformin, which just started 5 months ago. She has no medication side effects at time. She states that she feels healthy, is taking better care of he than in the past, and is looking forward to beginning t he new job. Medications Patient takes 850mg metformin twice daily, birth control pill - Yaz every morning with breakfast and uses her inhaler not daily and not more that twice in a week • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morni • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yester • Acetaminophen 500 -1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago) Allergies Patient is allergic to cats, penicillins, dust • Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Medical History Patient is dia betic and asthmatic. she uses medication in controlling her blood glucose. she was diagmosed of asthma when liitle and uses inhaler for the asthma. she also has PCOS which she takes the birth control pill Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler w she experiences exacerbations, such as around dust or cats. He asthma exacerbation was yesterday, which she resolved with he inhaler. She was last hospitalized for asthma in high school. Nev intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal s effects which have since dissipated. She monitors her blood sug once daily in the morning with average readings being around 90 She h as a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, ag First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ag Diagnosed w ith PCOS four months ago. For the past four month (after initiating Yaz) cycles regular (every 4 weeks) with moderat bleeding lasting 5 days. Has new male relationship, sexual conta not initiated. She plans to use condoms with sexual activity. Test negativ e for HIV/AIDS and STIs four months ago. Health Maintenance Patient states she is eating healthier and trying really hard to stay active. she has been exercising, walks for thirty or forty minutes four or five times a week and also goes for swimming once a week Last Pap smear 4 months ago. Last eye exam three months ago Last dental exam five months ago. PPD (negative) ~2 years ago Immunizations: Tetanus booster was received within the past ye influenza is not current, and human papillomavirus has been received. She reports that she believes she is up to date on child vaccines and received the meningococcal vaccine for college. S Has smoke detectors in the home, wears seatbelt in car, and doe not ride a b ike. Uses sunscreen. Guns, having belonged to her d are in the home, locked in parent’s room.