NR 509 Tina Jones Comprehensive – GRADED A+

NR 509 Tina Jones Comprehensive – GRADED A+ Comprehensive Assessment Ms. Jones is a pleasant, 29-year-old African American single woman who presents for a pre-employment physical. She is the pri mary source of the history. Ms. Jones off ers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Timeframe: 18 months after establishing primary care (Age: 29.5) Reason for visit: Patient requests a complete health assessment for a pre-employment physical. HPI: 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 eff ects 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 ROS: General: No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase. • Skin: Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes. • HEENT: Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no diffi culty swallowing, sore throat, voice changes, or swollen nodes. • Cardiovascular: Reports no palpitations, tachycardia, easy bruising, or edema. Respiratory: Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough. • Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive fl atulence. No food intolerances. • Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, fl ank pain, vaginal discharge or itching • Breasts: Reports no general breast problems, lumps, or pain. • Neurologic: Reports no dizziness, light -headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. • Musculoskeletal: Reports no muscle pain, joint pain, muscle weakness, or swelling. • Mental Health: Reports decreased stress and improved coping abilities have improved previous sleep diffi culties. Denies current feelings of depression, anxiety, or thoughts of suicide. Medications: Medications 1. Fluticasone propionate 110 mcg 2 puff s BID (last use: “this morning”) 2. Albuterol 90 mcg/spray MDI 2 puff s Q4H prn (last use: “a few month ago”) Assessment Tina Jones comes in for a follow-up/general physical exam. She is now on metformin, Proventil, and Flovent. She has glasses following a vision exam. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. She has begun keeping records of her asthma by monitoring her peak fl ow and tracking the use of her rescue inhaler. She is in a relationship and is now on birth control, which is helping to control her PCOS.