NRS 434 Week 4 Comprehensive Assessment Completed Shadow Health.

NRS 434 Week 4 Comprehensive Assessment Completed Shadow Health. Week 4: Comprehensive Assessment Results | Turned In Health Assessment, NRS-434VN Return to Assignment (/assignments/210197/) Your Results Lab Pass (/assignment_attempts/4765045/lab_pass.p Overview Transcript Subjective Data Collection Documentation / Electronic Health Record Documentation Objective Data Collection Documentation Plan My Exam Student Survey Vitals Student Documentation Model Documentation Vitals BP 128/82 HR 7 bpm RR 15 SPO2 99 Temp 37.2 C FVC 3.91 L FEV1 3.15 L FEV1/FVC - 0.81 • 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 is a 28 year old African American female unmarried. Identified patient by asking her to state her full name and DOB. 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 wit contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey Tina Jones is alert, oriented. She is well-nourished and developed. She presents with good hygiene and dressed appropriately. Ms. Jones is alert and oriented, seated upright on the examinatio table, and is in no apparent distress. She is well-nourished, well- developed, and dressed appropriately with good hygiene. Reason for Visit Ms. Jones states she was newly hired as an accounting clerk and is here for a pre-employment physical as a requirement for health insurance prior to her start date in about 2 weeks. "I came in because I'm required to have a recent physical exam the health insurance at my new job." This study source was downloaded by from CourseH on :47:27 GMT -05:00 History of Present Illness -Tina Jones denies and current concerns. She last saw medical attention 4 months ago for an anual GYN exam. -Medical history of Asthma and Type 2 Diabetes. 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 the new job. Medications Albuterol for asthma. PT uses 2-3 puffs PRN up to twice a week and sometimes not at all. Last used yesterday. Metformin 850 mg twice daily for diabetes control. YAZ for birth control. 1 tab PO every morning with breakfast. Advil prn for menstrual cramps. Patient states she has not used it in months. •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 Penicilin - last reaction was when she was a young child. She thinks it causes hives and rash. PT is allergic to cats which causes her asthma to act up. Denies food allergies •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 History of DM2 and Asthma. Hospitalized last at age 16 for asthma attacks. No history of cancer nor surgery. 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 has 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 with 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 negative for HIV/AIDS and STIs four months ago. Health Maintenance Exercise level: 30-40 minutes walking 4-5 days each week. Swims with a friend once a week. 2 doctors appointments this passed year. 5 months ago for a regular check up and a gynecologist for a pap smear a few weeks ago. 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 bike. Uses sunscreen. Guns, having belonged to her d are in the home, locked in parent’s room. Family History Lives with 50 yo mother and 15 yo sister. Father passed away 2.5 years ago from a car accident. Mother has a history of high cholesteral and hypertension. Grandmother is 82 YO with history of high cholesteral and hypertension. • Mother: age 50, hypertension, elevated cholesterol •Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes •Brother (Michael, 25): overweight •Sister (Britney, 14): asthma •Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol •Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol •Paternal grandmother: still living, age 82, hypertension •Paternal grandfather: died at age 65 of colon cancer, history of 2 diabetes •Paternal uncle: alcoholism •Negative for mental illness, other cancers, sudden death, kidne disease, sickle cell anemia, thyroid problems Social History Social history: spends time with church friends for bible studies and movie watching. Denies tobacco use. Denies illegal drug use. Consumes a few alcoholic beverages twice a month on weekends with friends at a bar and dancing. Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but move into own apartment in one month. Will begin her new posit two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study volunteering in her church, and dancing. Tina is active in her chu and describes a strong family and social support system. She st that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine methamphetamines, and heroin. Uses alcohol when “out with frie 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweete yogurt, lunch is vegetables with brown rice or sandwich on whea bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pet Participates in mild to moderate exercise four to five times per w consisting of walking, yoga, or swimming. Mental Health History Alert and oriented to self, place, and situation. Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or fac fasciculation. Speech is fluent, words are clear. Review of Systems - General Denies any acute illness, fevers, chills, fatigue No recent or frequent illness, fatigue, fevers, chills, or night swea States recent 10 pound weight loss due to diet change and exer increase. HEENT Student Documentation Model Documentation Subjective -Denies headaches, nausea, vommiting. -Wears corrective eye glasses. Visited optomotrist 3 months ago. Denies eye pain, irritation, or eye dryness -Reports no issues hearing, hearing changes, ear pain, or ear discharge. -Denies mouth or jaw pain. Reports no changes to her mouth, taste, and gum/tounge pain -Denies changes to sense of smell, sinus pain, or nasal discharge. -Denies sore throat, swalling pain, or voice changes Reports no current headache and no history of head injury or ac visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months Reports no general ear problems, no change in hearing, ear pain discharge. Reports no change in sense of smell, sneezing, epist sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with g tongue, or jaw. No current dental concerns, last dental visit was months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.