Comprehensive Assessment _ Completed _ Shadow Health

Comprehensive Assessment Results | Turned In Patient Assessment and Health Literacy - January 2019, NUR 325 Return to Assignment Comprehensive Assessment _ Completed _ Shadow Health Your Results Lab Pass Documentation / Electronic Health Record Documentation Vitals Student Documentation Model Documentation Vitals BP 128/82, Temp 37.2, Pulse 78 Resps 15 SpO2 99%. • 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 Provides full name and verifies date of birth. Ms. Jones is a pleasant, 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 a pleasant, well-groomed 28 year old AFrican American female wearing glasses to correct nearsightedness, 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 Ms. Jones presents to clinic today for a pre- employment physical. "I came in because I'm required to have a recent physical exam for the health insurance at my new job." Student Documentation Model Documentation History of Present Illness REports no current health issues. Hx of Asthma (Albuterol); Diabetes (Metformin) and Polycystic Ovaria Syndrome (Yaz). Patient rates current health at an 8/10. 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; Albuterol number of mcg not available on visit; 2-3 puffs INH PRN / asthma; Yaz 1 tab PO daily. Advil OTC 200 mg PO PRN • 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 PCN, pediatric onset, rash / urticaria. CAts; asthma exacerbator, runny nose. • 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. Student Documentation Model Documentation …………………………………………………………CONTINUED…………………………………………………..