Shadow Health Comprehensive Assessment
Documentation (Tina Jones) exam with solved solution
Students also studied
C
Terms in this set (21)
Vitals • 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 Ms. Jones is a 28-year-old African American single woman
who presents for a pre-employment physical. She is the
primary source of the history. Ms. Jones offers information
freely and without contradiction. Speech is clear and
coherent. She maintains eye contact throughout the interview.
General Survey Ms. Jones is alert and oriented, seated upright on the
examination table, and is in no apparent distress. She is well-
nourished, well-developed, and dressed appropriately with
good hygiene.
Reason for Visit "I came in because I'm required to have a recent
physical exam for the health insurance at my new
job."
, History of Present Illness Ms. Jones reports that she recently obtained employment at
Smith, Stevens, Stewart, Silver & Company. She needs to
obtain a pre-employment physical prior to initiating
employment. Today she denies any acute concerns. Her last
healthcare visit was 4 months ago, when she received her
annual gynecological exam at Shadow Health General Clinic.
Ms. Jones states that the gynecologist diagnosed her with
polycystic ovarian syndrome and prescribed oral
contraceptives at that visit, which she is tolerating well. She
has type 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, 850 mg PO BID (last use: this morning) •
Drospirenone and ethinyl estradiol PO QD (last use: this
morning) • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn
(last use: yesterday) • Acetaminophen 500-1000 mg PO prn
(headaches) • Ibuprofen 600 mg PO TID prn (menstrual
cramps: last taken 6 weeks ago)
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 Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler
when she experiences exacerbations, such as around dust or
cats. Her last asthma exacerbation was yesterday, which she
resolved with her inhaler. She was last hospitalized for asthma
in high school. Never intubated. Type 2 diabetes, diagnosed at
age 24. She began metformin 5 months ago and initially had
some gastrointestinal side effects which have since dissipated.
She monitors her blood sugar 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, age 11. First sexual
encounter at age 18, sex with men, identifies as heterosexual.
Never pregnant. Last menstrual period 2 weeks ago.
Diagnosed with PCOS four months ago. For the past four
months (after initiating Yaz) cycles regular (every 4 weeks) with
moderate bleeding lasting 5 days. Has new male relationship,
sexual contact not initiated. She plans to use condoms with
sexual activity. Tested negative for HIV/AIDS and STIs four
months ago.
Documentation (Tina Jones) exam with solved solution
Students also studied
C
Terms in this set (21)
Vitals • 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 Ms. Jones is a 28-year-old African American single woman
who presents for a pre-employment physical. She is the
primary source of the history. Ms. Jones offers information
freely and without contradiction. Speech is clear and
coherent. She maintains eye contact throughout the interview.
General Survey Ms. Jones is alert and oriented, seated upright on the
examination table, and is in no apparent distress. She is well-
nourished, well-developed, and dressed appropriately with
good hygiene.
Reason for Visit "I came in because I'm required to have a recent
physical exam for the health insurance at my new
job."
, History of Present Illness Ms. Jones reports that she recently obtained employment at
Smith, Stevens, Stewart, Silver & Company. She needs to
obtain a pre-employment physical prior to initiating
employment. Today she denies any acute concerns. Her last
healthcare visit was 4 months ago, when she received her
annual gynecological exam at Shadow Health General Clinic.
Ms. Jones states that the gynecologist diagnosed her with
polycystic ovarian syndrome and prescribed oral
contraceptives at that visit, which she is tolerating well. She
has type 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, 850 mg PO BID (last use: this morning) •
Drospirenone and ethinyl estradiol PO QD (last use: this
morning) • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn
(last use: yesterday) • Acetaminophen 500-1000 mg PO prn
(headaches) • Ibuprofen 600 mg PO TID prn (menstrual
cramps: last taken 6 weeks ago)
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 Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler
when she experiences exacerbations, such as around dust or
cats. Her last asthma exacerbation was yesterday, which she
resolved with her inhaler. She was last hospitalized for asthma
in high school. Never intubated. Type 2 diabetes, diagnosed at
age 24. She began metformin 5 months ago and initially had
some gastrointestinal side effects which have since dissipated.
She monitors her blood sugar 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, age 11. First sexual
encounter at age 18, sex with men, identifies as heterosexual.
Never pregnant. Last menstrual period 2 weeks ago.
Diagnosed with PCOS four months ago. For the past four
months (after initiating Yaz) cycles regular (every 4 weeks) with
moderate bleeding lasting 5 days. Has new male relationship,
sexual contact not initiated. She plans to use condoms with
sexual activity. Tested negative for HIV/AIDS and STIs four
months ago.
