1/12/2020 Week 4: Comprehensive Assessment | Completed | Shadow Health
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information (https://support.shadowhealth.com/hc/en-us/articles/360009548313)
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
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Vitals
Documentation
Plan My Exam
Student Documentation Model Documentation
Student Survey Vitals
• Height: 170 cm
BP 128/82 • Weight: 84 kg
HR 7 bpm • BMI: 29.0
RR 15 • Blood Glucose: 100
SPO2 99 • RR: 15
Temp 37.2 C • HR: 78
FVC 3.91 L • BP:
FEV1 3.15 L • Pulse Ox: 99%
FEV1/FVC - 0.81 • Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African American single wo
who presents for a pre-employment physical. She is the primary
Tina Jones is a 28 year old African American female unmarried. source of the history. Ms. Jones offers information freely and wit
Identified patient by asking her to state her full name and DOB. 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 examinatio
Tina Jones is alert, oriented. She is well-nourished and developed. table, and is in no apparent distress. She is well-nourished, well-
She presents with good hygiene and dressed appropriately. developed, and dressed appropriately with good hygiene.
Reason for Visit
Ms. Jones states she was newly hired as an accounting clerk and is "I came in because I'm required to have a recent physical exam
here for a pre-employment physical as a requirement for health the health insurance at my new job."
insurance prior to her start date in about 2 weeks.
1/6
, 1/12/2020 Week 4: Comprehensive Assessment | Completed | Shadow Health
Student Documentation Model Documentation
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
History of Present Illness any acute concerns. Her last healthcare visit was 4 months ago,
when she received her annual gynecological exam at Shadow H
-Tina Jones denies and current concerns. She last saw medical General Clinic. Ms. Jones states that the gynecologist diagnosed
attention 4 months ago for an anual GYN exam. with polycystic ovarian syndrome and prescribed oral contracept
-Medical history of Asthma and Type 2 Diabetes. 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
• Metformin, 850 mg PO BID (last use: this morning)
Albuterol for asthma. PT uses 2-3 puffs PRN up to twice a week and
• Drospirenone and ethinyl estradiol PO QD (last use: this morni
sometimes not at all. Last used yesterday.
• Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yester
Metformin 850 mg twice daily for diabetes control.
• Acetaminophen 500-1000 mg PO prn (headaches)
YAZ for birth control. 1 tab PO every morning with breakfast.
• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6
Advil prn for menstrual cramps. Patient states she has not used it in
weeks ago)
months.
Allergies
• Penicillin: rash
Penicilin - last reaction was when she was a young child. She thinks it • Denies food and latex allergies
causes hives and rash. • Allergic to cats and dust. When she is exposed to allergens she
PT is allergic to cats which causes her asthma to act up. states that she has runny nose, itchy and swollen eyes, and
Denies food allergies increased asthma symptoms.
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
Medical History effects which have since dissipated. She monitors her blood sug
once daily in the morning with average readings being around 90
History of DM2 and Asthma. Hospitalized last at age 16 for asthma She has a history of hypertension which normalized when she
attacks. No history of cancer nor surgery. 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.
Last Pap smear 4 months ago. Last eye exam three months ago
Health Maintenance Last dental exam five months ago. PPD (negative) ~2 years ago
Immunizations: Tetanus booster was received within the past ye
Exercise level: 30-40 minutes walking 4-5 days each week. Swims influenza is not current, and human papillomavirus has been
with a friend once a week. received. She reports that she believes she is up to date on child
2 doctors appointments this passed year. 5 months ago for a regular vaccines and received the meningococcal vaccine for college. S
check up and a gynecologist for a pap smear a few weeks ago. 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.
If you are using Safari and have issues with audio in your assignment, please click here for assistance. Click here for more (/site_notice_dismissals?from_flash=true&site_noti
information (https://support.shadowhealth.com/hc/en-us/articles/360009548313)
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
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Vitals
Documentation
Plan My Exam
Student Documentation Model Documentation
Student Survey Vitals
• Height: 170 cm
BP 128/82 • Weight: 84 kg
HR 7 bpm • BMI: 29.0
RR 15 • Blood Glucose: 100
SPO2 99 • RR: 15
Temp 37.2 C • HR: 78
FVC 3.91 L • BP:
FEV1 3.15 L • Pulse Ox: 99%
FEV1/FVC - 0.81 • Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African American single wo
who presents for a pre-employment physical. She is the primary
Tina Jones is a 28 year old African American female unmarried. source of the history. Ms. Jones offers information freely and wit
Identified patient by asking her to state her full name and DOB. 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 examinatio
Tina Jones is alert, oriented. She is well-nourished and developed. table, and is in no apparent distress. She is well-nourished, well-
She presents with good hygiene and dressed appropriately. developed, and dressed appropriately with good hygiene.
Reason for Visit
Ms. Jones states she was newly hired as an accounting clerk and is "I came in because I'm required to have a recent physical exam
here for a pre-employment physical as a requirement for health the health insurance at my new job."
insurance prior to her start date in about 2 weeks.
1/6
, 1/12/2020 Week 4: Comprehensive Assessment | Completed | Shadow Health
Student Documentation Model Documentation
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
History of Present Illness any acute concerns. Her last healthcare visit was 4 months ago,
when she received her annual gynecological exam at Shadow H
-Tina Jones denies and current concerns. She last saw medical General Clinic. Ms. Jones states that the gynecologist diagnosed
attention 4 months ago for an anual GYN exam. with polycystic ovarian syndrome and prescribed oral contracept
-Medical history of Asthma and Type 2 Diabetes. 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
• Metformin, 850 mg PO BID (last use: this morning)
Albuterol for asthma. PT uses 2-3 puffs PRN up to twice a week and
• Drospirenone and ethinyl estradiol PO QD (last use: this morni
sometimes not at all. Last used yesterday.
• Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yester
Metformin 850 mg twice daily for diabetes control.
• Acetaminophen 500-1000 mg PO prn (headaches)
YAZ for birth control. 1 tab PO every morning with breakfast.
• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6
Advil prn for menstrual cramps. Patient states she has not used it in
weeks ago)
months.
Allergies
• Penicillin: rash
Penicilin - last reaction was when she was a young child. She thinks it • Denies food and latex allergies
causes hives and rash. • Allergic to cats and dust. When she is exposed to allergens she
PT is allergic to cats which causes her asthma to act up. states that she has runny nose, itchy and swollen eyes, and
Denies food allergies increased asthma symptoms.
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
Medical History effects which have since dissipated. She monitors her blood sug
once daily in the morning with average readings being around 90
History of DM2 and Asthma. Hospitalized last at age 16 for asthma She has a history of hypertension which normalized when she
attacks. No history of cancer nor surgery. 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.
Last Pap smear 4 months ago. Last eye exam three months ago
Health Maintenance Last dental exam five months ago. PPD (negative) ~2 years ago
Immunizations: Tetanus booster was received within the past ye
Exercise level: 30-40 minutes walking 4-5 days each week. Swims influenza is not current, and human papillomavirus has been
with a friend once a week. received. She reports that she believes she is up to date on child
2 doctors appointments this passed year. 5 months ago for a regular vaccines and received the meningococcal vaccine for college. S
check up and a gynecologist for a pap smear a few weeks ago. 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.
