NUR 325 Comprehensive Assessment Results | Turned In Patient Assessment and Health Literacy ,100% CORRECT
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Course
NUR 325
Institution
NUR 325
NUR 325 Comprehensive Assessment Results | Turned In Patient Assessment and Health Literacy
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Your Results
Lab Pass
Documentation / Electronic Health Record
Documentation
Vitals
Student Documentation Model Documentation
Vitals
BP ...
Ms. Jones is a pleasant, 28-year-old
Identifying Data & Reliability African American single woman who
presents for a pre- employment
Provides full name and verifies physical. She is the primary source of
date of birth.
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 alert and oriented, seated
Ms. Jones is a pleasant, well- upright on the examination table, and
groomed 28 year old AFrican is in no apparent distress. She is well-
American female wearing glasses to nourished, well-developed, and
correct nearsightedness, dressed appropriately with good
hygiene.
Reason for Visit
"I came in because I'm required to
Ms. Jones presents to clinic have a recent physical exam for the
today for a pre- employment health insurance at my new job."
physical.
This study source was downloaded by 100000802531269 from CourseHero.com on 12-03-2022 22:59:57 GMT -
06:00
Ms. Jones reports that she recently
obtained employment at Smith,
Stevens, Stewart, Silver & Company.
She needs to obtain a pre-
employment physical prior to
History of Present Illness
initiating employment. Today she
denies any acute concerns. Her last
REports no current health issues. Hx
healthcare visit was 4 months ago,
of Asthma (Albuterol); Diabetes
when she received her annual
(Metformin) and Polycystic Ovaria
gynecological exam at Shadow Health
Syndrome (Yaz). Patient rates current
General Clinic. Ms. Jones states that
health at an 8/10.
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.
• Metformin, 850 mg PO BID (last use: this
Medications
morning)
• Drospirenone and ethinyl
Metformin 850 mg PO BID;
Albuterol number of mcg not estradiol PO QD (last use: this
available on visit; 2-3 puffs INH PRN / morning)
asthma; • Albuterol 90 mcg/spray MDI 1-3
Yaz 1 tab PO daily. puffs Q4H prn (last use: yesterday)
Advil OTC 200 mg PO PRN • Acetaminophen 500-1000 mg PO prn
(headaches)
• Ibuprofen 600 mg PO TID prn
(menstrual cramps: last taken 6
weeks ago)
This study source was downloaded by 100000802531269 from CourseHero.com on 12-03-2022 22:59:57 GMT -06:00
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