NURSING MSN 572Advanced Physical Assessment Across the Lifespan (FNP

Comprehensive Assessment (120 min minimum) Results | Turned In Advanced Physical Assessment Across the Lifespan (FNP) - USU - February 2021, msn572 Return to Assignment (/assignments/470720/) Documentation / Electronic Health Record Vitals Student Documentation Model Documentation Vitals BP 128/82 HR 78 RR- 15 Temp 37.2c O2: 99% • Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F Health History Student Documentation Model Documentation Identifying Data & Reliability Tina Jones, 28yr old AA female, DOB 2/14, came to the clinic with her mother for a physical for a new job. She appears to be a good historian and answers all questions appropriately. 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 history. Ms. Jones offers information freely and with contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey Patient is well dress, hygeine good with no odor, poster upright, mobility is stable, attentive to all questios, attitude good with positive espressions. A&Ox4, very pleasant and cooperative. breathing is at ease. VS stable. eye exam 20/20 with snellan chart. HT, weight and BMI charted. VS taken. Ms. Jones is alert and oriented, seated upright on the examinatio table, and is in no apparent distress. She is well-nourished, welldeveloped, and dressed appropriately with good hygiene. Reason for Visit physical for new job “I came in because I'm required to have a recent physical exam f the health insurance at my new job.” Your Results Lab Pass (/assignment_attempts/9539340/lab_ Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Documentation Support This study source was downloaded by from CourseH on :16:57 GMT -05:00 3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health Student Documentation Model Documentation History of Present Illness patient came in for a physical exam for a new job. no complaints of any current illnesses, patient states she has been feeling really good and healthy, exercising and eating well. Histroy Diabetes, asthma which she takes medications for and both are under control. Last seen by a health care provider was 4 months ago for a GYN exam. Last physical exam was 5 months ago. Last eye exam 3 months ago. last dental cleaning 5 months ago. Ms. Jones reports that she recently obtained employment at Sm Stevens, Stewart, Silver & Company. She needs to obtain a preemployment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 month ago, when she received her annual gynecological exam at Shado Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed contraceptives at that visit, which she is tolerating well. She has 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job. Medications Metformin 850mg, BID, oral flovent-88mcg per spray, 2 puff, BID. proventil-90 mcg, 2 puffs, as needed Yaz-once daily with breakfast Advil for cramping as needed denies any adverse reactions to medication • Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: t