NR 509 Comprehensive Assessment _ Completed _ Shadow Health {TINA JONES} Vitals Documentation

1/12/2020

Week 4: Comprehensive Assessment | Completed | Shadow Health

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Week 4: Comprehensive Assessment Results | Turned In Health Assessment, NRS-434VN Return to Assignment (/assignments/210197/)

Your Results

Overview

Documentation / Electronic Health Record

Transcript

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Lab Pass (/assignment_attempts/4765045/lab_pass.p

Subjective Data Collection Objective Data Collection Documentation Plan My Exam Student Survey

Documentation

Vitals

Student Documentation Vitals

BP 128/82 HR 7 bpm RR 15 SPO2 99 Temp 37.2 C FVC 3.91 L FEV1 3.15 L FEV1/FVC - 0.81

Model Documentation

• 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

Ms. Jones is a pleasant, 28-year-old African American single wom who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and with contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

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Tina Jones is a 28 year old African American female unmarried.

Identified patient by asking her to state her full name and DOB.

General Survey Tina Jones is alert, oriented. She is well-nourished and developed.

She presents with good hygiene and dressed appropriately.

Ms. Jones is alert and oriented, seated upright on the examinatio table, and is in no apparent distress. She is well-nourished, welldeveloped, and dressed appropriately with good hygiene.

Reason for Visit Ms. Jones states she was newly hired as an accounting clerk and is here for a pre-employment physical as a requirement for health insurance prior to her start date in about 2 weeks.

"I came in because I'm required to have a recent physical exam f the health insurance at my new job."

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Student Documentation

History of Present Illness -Tina Jones denies and current concerns. She last saw medical attention 4 months ago for an anual GYN exam.

-Medical history of Asthma and Type 2 Diabetes.

Model Documentation

Ms. Jones reports that she recently obtained employment at Smi Stevens, Stewart, Silver & Company. She needs to obtain a preemployment physical prior to initiating employment. Today she de any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow He General Clinic. Ms. Jones states that the gynecologist diagnosed with polycystic ovarian syndrome and prescribed oral contracepti 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) • Drospirenone and ethinyl estradiol PO QD (last use: this mornin • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yester • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)

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Albuterol for asthma. PT uses 2-3 puffs PRN up to twice a week and sometimes not at all. Last used yesterday.

Metformin 850 mg twice daily for diabetes control.

YAZ for birth control. 1 tab PO every morning with breakfast.

Advil prn for menstrual cramps. Patient states she has not used it in months.

Allergies

Penicilin - last reaction was when she was a young child. She thinks it causes hives and rash.

PT is allergic to cats which causes her asthma to act up.

Denies food allergies

Medical History

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History of DM2 and Asthma. Hospitalized last at age 16 for asthma attacks. No history of cancer nor surgery.

Health Maintenance

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Exercise level: 30-40 minutes walking 4-5 days each week. Swims with a friend once a week.

2 doctors appointments this passed year. 5 months ago for a regular check up and a gynecologist for a pap smear a few weeks ago.

• 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.

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 her 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 effects which have since dissipated. She monitors her blood suga 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, 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 months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual conta not initiated. She plans to use condoms with sexual activity. Teste negative for HIV/AIDS and STIs four months ago.

Last Pap smear 4 months ago. Last eye exam three months ago Last dental exam five months ago. PPD (negative) ~2 years ago.

Immunizations: Tetanus booster was received within the past yea influenza is not current, and human papillomavirus has been received. She reports that she believes she is up to date on child vaccines and received the meningococcal vaccine for college. Sa 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.

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Student Documentation

Family History Lives with 50 yo mother and 15 yo sister. Father passed away 2.5 years ago from a car accident. Mother has a history of high cholesteral and hypertension. Grandmother is 82 YO with history of high cholesteral and hypertension.

• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidne disease, sickle cell anemia, thyroid problems

Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but move into own apartment in one month. Will begin her new posit two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study volunteering in her church, and dancing. Tina is active in her chu and describes a strong family and social support system. She sta that family and church help her cope with stress. No tobacco.

Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with frie 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweete yogurt, lunch is vegetables with brown rice or sandwich on whea bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pet Participates in mild to moderate exercise four to five times per we consisting of walking, yoga, or swimming.

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Social History

Model Documentation

Social history: spends time with church friends for bible studies and movie watching.

Denies tobacco use.

Denies illegal drug use.

Consumes a few alcoholic beverages twice a month on weekends with friends at a bar and dancing.

Mental Health History

Alert and oriented to self, place, and situation.

Review of Systems - General

Denies any acute illness, fevers, chills, fatigue

Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or fac fasciculation. Speech is fluent, words are clear.

No recent or frequent illness, fatigue, fevers, chills, or night swea States recent 10 pound weight loss due to diet change and exerc increase.

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Student Documentation Subjective

-Denies headaches, nausea, vommiting. -Wears corrective eye glasses. Visited optomotrist 3 months ago. Denies eye pain, irritation, or eye dryness -Reports no issues hearing, hearing changes, ear pain, or ear discharge.

-Denies mouth or jaw pain. Reports no changes to her mouth, taste, and gum/tounge pain -Denies changes to sense of smell, sinus pain, or nasal discharge.

-Denies sore throat, swalling pain, or voice changes

Model Documentation

Reports no current headache and no history of head injury or acu visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months Reports no general ear problems, no change in hearing, ear pain discharge. Reports no change in sense of smell, sneezing, epista sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with g tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.

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Student Documentation Objective -Head is symetrical no traumatic evidence.

-Eyes bilaterally no edema, discharge, droop, and equal distribution of eye lashes and brows. Bilaterally conjunctiva are pink, no lesions, sclerra are white. Bilateral PERRLA. Bilaterally EOM intact.

SNELLEN: with corrective lens: 20/20 both eyes..

-Ears: bilaterally TM intact and gray. Hearing intact bilaterally with whisper test.

-Nose: nasal tract mucosa are pink and moist. No deviated septum.

-Mouth: Mucosa is moist. No signs of ulcers or lesions. Tonsil is midline. Positive gag reflex. Teeth appear intact without infection.

-Neck: supple no goiter, thyroid does not have nodules, negative for lympadeopathy

Model Documentation

Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptos edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopath changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with correc lenses. TMs intact and pearly gray bilaterally, positive light reflex Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula r midline on phonation. Gag reflex intact. Dentition without evidenc caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Respiratory Student Documentation

Model Documentation

Subjective Reports no shortness of breath, wheezing, chest pain, dyspnea, cough.

is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m Denies shortness of breathe, trouble breathing, or cough.

Asthma under control with inhaler.

Objective

-Bilaterally chest is symetrical with breathe expansion. Lung souds clear to auscultation. Resonant upon percussion.

- FVC 3.91 L, FEV1-FVC 80.56%

Chest is symmetric with respiration, clear to auscultation bilatera without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Cardiovascular

Student Documentation

Model Documentation

Subjective

Denies palpitations, tachycardia

Reports no palpitations, tachycardia, easy bruising, or edema.

Objective

Heart rate is regular, S1, S2, without murmurs, gallops, or rubs.

Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves or lifts. Bilate peripheral pulses equal bilaterally, capillary refill less than 3 seco No peripheral edema.

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-Normal heart rate and rhythm. S1 and S2 auscultated.

-Bilateral coratids equal no bruit.

-PMI located 5th intercostal space midclavicularly.

-Pulses palpated bilaterally in perippherals. Capillary refills less than 3 seconds. Extermities present no edema.

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Abdominal

Student Documentation Subjective

GI: Denies Nausea, Vomiting, Diarrhea. Reports no pain. Denies food intolerence.

GU: Denies polyuria, hematuria, vaginal pain discharge or itching.

Model Documentation

Gastrointestinal: Reports no nausea, vomiting, pain, constipation diarrhea, or excessive flatulence. No food intolerances.

Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, pain, vaginal discharge or itching.

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Student Documentation Objective Abdomen: symetrical, protuberant, no obvious masses, trauma, hair midline from umbilicus to pubis. No tenderness or gaurding, Palpitation to organs are normal. Bowel sounds are normal in all quadrents and tympanic.

Model Documentation

Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Musculoskeletal Student Documentation

Model Documentation

Subjective Denies muscle pain or weakness. No Joint pain.

Reports no muscle pain, joint pain, muscle weakness, or swelling

Objective Bilateral upper and lower extremities without swelling, masses, o deformity and with full range of motion. No pain with movement.

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-Upper and lower extremities bilaterally are 5/5. No masses, swelling, deformities -Full ROM -No pain

Neurological

Student Documentation

Model Documentation

Subjective

Denies dizzyness, loss of coordiation, light headedness, seizues, or loss of balance.

Objective

Normal bilateral rapid alternating movements, sterognosis, and trace sensations.

Sensation with monifilament decreased on platar surfaces.

Reports no dizziness, light-headedness, tingling, loss of coordina or sensation, seizures, or sense of disequilibrium.

Strength 5/5 bilateral upper and lower extremities. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equa bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin, Hair & Nails

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Student Documentation

Model Documentation

Subjective

Reports improved acne due to oral contraceptives. Skin on neck stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.

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History of acne but has improved with birthcontrol. She reports skin darkening on her neck has decreased. Denies changes to hair or nails.

Objective

Skin darkening on back of neck. No nail ridges or abnormalties. Acne scattered on face. Scalp and skin appears normal.

Scattered pustules on face and facial hair on upper lip, acanthos nigricans on posterior neck.

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Week 4: Comprehensive Assessment | Completed | Shadow Health

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