NR 509 Comprehensive Assessment; Tina Jones-Lab Report

Complete



Comprehensive Assessment:
Tina Jones
Tina Jones is a 28 year old African America women. She came into the clinic for
a physical exam.
She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. She is required to
have a physical exam for her health insurance. Tina's health history was taken, a physical
assessment was done and a plan of care was made.
Health History
Health history is a very important part of assessment for practitioners. When
interviewing the patient the practitioner is able to get a health history and the history of
the patients chief complaint. Through the interview process the practitioner is als
o able to find out what the patient believes is most important about their health (Bickley, 2013).
Tina is a 28 year old African American women. She is in the clinic today for a physical
exam for her new job. She is the primary source of health history. Tina's speech
is clear and coherent. She maintains eye contact throughout the interview. Tina is alert
and oriented. She is well-developed and dress appropriately with good hygiene.
She does not appear to be in any distress.
Tina is allergic to cats, she states that she tries to avoid cats but when she is around them her
asthma "acts up" (T. Jones, Shadow Health Interview, February 13, 2016). She states that she
has tightness in her chest and wheezing. She is allergic to PCN. She states that she "got a ra
sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). She
denies any food and latex allergies. She denies having any recent allergies to dust or pol
len. She states that she has had problems in the past but they have not h
appened in "a while" (T. Jones, Shadow Health Interview, February 13, 2016). She states that
her daily inhaler has helped with her environmental allergies.
Tina has been diagnosed with diabetes, asthma and polycystic ovarian syndrome (PCOS).
Tina was diagnosed with Diabetes at age 24. Tina checks her blood sugar once a day, in the
morning. Her diabetes is being treated with metformin 850 mg PO BID. She has changed her
diet recently to help with her diabetes. She limits her carbohydrates and avoids sugar. Tina was
diagnosed with asthma at age 2 1/2. She is treating her asthma with a daily inhaler as well as
a rescue inhaler. Her daily inhaler is Flovent 88mcg/spray MDI 2 puff BID. Her rescue inhaler is
90 mcg/spray MDI 2 puff PRN for shortness of breath. She states that her daily inhaler has
improved her asthma. She states that her last asthma attack was 3 months ago. She states that
when she has an attack her chest feel tight and she has wheezing. She states that it feels like
she "cant' get enough air”. Her last asthma related hospitalization was when she was 16. She
states that her asthma is worst when around cats but she also has problems with dust and
running up stairs. Tina was recently diagnosed with
PCOS
.
Her OB/GYN started her on Yaz birth
control to treat the PCOS. The
Yaz
is
being used to co
ntrol
and lessen symptoms of
PCOS.
She has noticed that her periods are more regular
and her cramps are not "as bad
"
(T.

, Complete


Jones, Shadow Health Interview, February 13, 2016).
She also states that her
menstrual flow is medium. She had a pap
smear done 4 months ago.
She uses
Advil
to
treat her
cramps
when she gets them (T. Jones, Shadow Health Interview, February 13,
2016).
TINA JONES ASSESSMENT
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4
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She has a family history of hypertension (HTN), high cholesterol, diabetes, and
colon cancer. Her mother is still aliv
e and has high cholesterol and HTN. Her father died
a year ago in a car accident. He had a history of HTN, high cholesterol and diabetes.
Tina's paternal Grandfather died from Colon cancer and also had HTN and diabetes. Her
paternal Grandmother is living
and has a history of HTN. Her maternal Grandfather died
from a heart attack and had a history of HTN and high cholesterol. Tina's maternal
Grandmother died from a stroke and had a history of HTN and high cholesterol. Her
Sister has asthma and her Brother i
s over
-
weight
(T. Jones, Shadow Health Interview,
February 13, 2016)
.
A review of systems was done with Tina.
The practitioner found the following:
General:
Tina has lost some weight due to diet and exercise changes. Pt denies any fever
or night sweats. P
t is alert and oriented She is coherent to answer questions. HEENT:
Denies fever. Reports that she has not been sick recently. She states that she has been
sleeping well and has a good amount of energy. Tina denies any ear problems. She denies
any hearing
problems
or pain in her ears. She is wearing eye glasses. She denies any
recent blurry vision. She had an eye appointment 3 months ago. She states that at her eye
appointment the doctor stated that she was near sighted and needed to wear glasses. She
denie
s recent headaches. She states that she has not had a hea
da
che in 6 months. She
thinks that her last headache was when she was studying. Denies any nasal problems or
surgeries. She states that she only sneezes when she is around cats. She denies having any
nosebleeds. Denies any mouth problems. Denies any changes in taste. Denies mouth pain