Shadow Health Tina Jones. Shadow Comp Objective
RR: 20
HR: 89
BP: 140/81
Pulse Ox:97% RA
Oral Temp: (Afebrile)
Height: 170 cm
Weight:89 Kg
BMI: 30.8
BCG:
FVC = 9.91 L
FEV1 = 3.15 L
RATIO =80.56%
Ms. Jones is a pleasant, 28-year-old African American single woman here a pre- employment
...
NRS-434 Shadow Health Tina Jones. Shadow Comp
Objective
Shadow Health Tina Jones. Shadow Comp Objective
RR: 20
HR: 89
BP: 140/81
Pulse Ox:97% RA
Oral Temp: (Afebrile)
Height: 170 cm
Weight:89 Kg
BMI: 30.8
BCG:
FVC = 9.91 L
FEV1 = 3.15 L
RATIO =80.56%
Ms. Jones is a pleasant, 28-year-old African American single woman here a pre- employment
physical. Offering the primary source of the history, her speech is clear and concise and eye
contact is appropriate throughout the exam.
General Survey:
Ms. Jones is alert, oriented times four, appearing to be in no distress. She is well-nourished, fully
developed. Her skin and hygiene good.
Reason:
Ms. Jones stated, “I came in because I'm required to have a recent physical exam for the health
insurance at my new job.”
HPI:
Ms. Jones stating, she needs a pre-employment physical for employment with Smith, Stevens,
Stewart, Silver & Company. She denies any acute concerns. Her last healthcare visit was 4
months ago, at which time she went in for her annual gynecology appointment with her Nurse
Practitioner at Shadow Health General Clinic. Ms. Jones states at that time she was diagnosed
with PCOS (polycystic ovarian syndrome). Ms. Jones prover prescribed oral contraceptives at
that time; she denies any unwanted side effects from the Yaz prescribed. Ms. Jones has asthma
she controls with a daily inhaler and a rescue inhaler, also avoiding her primary allergens of cats
and dust as best she can. She is also doing Peek and Flow meter breathing at home, stating she
feels her asthma is under control at this time. Also having type 2 diabetes, which she is
controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no
unwanted 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”.
This study source was downloaded by 100000830772748 from CourseHero.com on 04-01-2022 04:11:58 GMT -05:00
, NRS-434 Shadow Health Tina Jones. Shadow Comp
Objective
Meds:
• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
• Metformin, 850 mg PO BID (last use: this morning)
• Drospirenone and ethinyl estradiol PO QD (last use: this morning)
• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago)
• 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 Hx:
Asthma diagnosed age 2 1/2. She uses albuterol HHI prn, last asthma exacerbation was three
months ago, resolved with inhaler. She was last hospitalized for asthma in high school.
Never intubated. Type 2 diabetes diagnosed at age 24. She is taking metformin, started taking 5
months ago with initial flatulence. She is now eating yogurt daily and states this has caused the
GI side effects to subside. She monitors her blood sugar in the morning only, stating average
BCG reading is 90. Personal history of hypertension, this is currently stable with diet and
exercise. Denies any surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18,
sex with men, states seeing only men. Never pregnant. Last period 2 weeks ago. Diagnosed with
PCOS four months ago. States menstrual cycles have regulated since being on Yaz this past four
months. She plans using condoms with sexual activity. States a negative test for STIs four
months ago.
Health Maintenance:
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
year, influenza is not current, and human papillomavirus has not been received. She reports that
she believes she is up to date on childhood vaccines and received the meningococcal vaccine for
college. Safety: Has smoke detectors in the home, wears seatbelt in car. Uses sunscreen. Guns,
having belonged to her dad, are in the home, locked in parent’s room.
This study source was downloaded by 100000830772748 from CourseHero.com on 04-01-2022 04:11:58 GMT -05:00
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