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Week 9: Shadow Health DCE Comprehensive Physical Exam Tina Jones
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Week 9: Shadow Health DCE Comprehensive Physical Exam Tina Jones
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Week 9: Shadow Health DCE Comprehensive Physical ExamStudent Name
Walden University
NURS-6512N-56-Advanced Health Assessment
Dr. Kimberly Olszewski
July 30, 2021
, COMPREHENSIVE PHYSICAL EXAM – WEEK 9 2
Week 9: Shadow Health DCE Comprehensive Physical Exam
SUBJECTIVE DATA: Tina Jones, 28 years old, African American female
Reason for Visit: Pre-employment physical
History of Present Illness (HPI): Tina Jones is a 28-year-old African American female
who presents today for a complete head-to-toe pre-employment physical exam. She
recently gained employment as an accounting clerk at Smith, Stevens, Stewart, Silver &
Company where she begins in two weeks. She denies any acute concerns currently. She
has had regular check ups for her medical health including a gynecological visit four
months ago where she was diagnosed with PCOS and started on an oral contraceptive
drospirenone / ethinyl estradiol. At her dental exam five months ago she denies any
current dental problems. Her last eye exam was three months ago where she was given
prescription glasses to always wear and will follow up in one year. Her last physical
exam was five months ago where she was prescribed metformin for her diabetes, and a
daily inhaler for her asthma.
Medications: Metformin 850mg tabs daily for diabetes control, drospirenone/ethinyl
estradiol 1 pill daily for birth control/PCOS treatment, Flovent daily inhaler 2 puffs twice
a day, Albuterol (Proventil) Inhaler: 90mcg per spray, 2-3 sprays PRN for asthma
symptoms, Advil 200mg tabs, 3-4 tabs PRN for menstrual cramps
Allergies: Penicillin (rash, hives), Cats (sneezing, itchy eyes, asthma symptoms), Dust
(sneezing, wheezing, itchy eyes), no reported latex allergy.
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