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4/25/2020 Week 4: Comprehensive Assessment | Completed | Shadow HealthWeek 4: Comprehensive Assessment Results | Completed
Health Assessment - GCU - March 2020, nrs-434vn
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Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Vitals
Documentation
Plan My Exam
Student Documentation Model Documentation
Student Survey
Vitals • Height: 170 cm
• Weight: 84 kg
B/P - 128/82mmHg • BMI: 29.0
HR - 78bpm • Blood Glucose: 100
RR - 15cpm • RR: 15
T - 37.2c • HR: 78
SpO2 - 99% • BP:
weight - 185lb • 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 wo
who presents for a pre-employment physical. She is the primary
Ms Tina, 28 year old African American, female, plesant, calm and co- source of the history. Ms. Jones offers information freely and wit
operative. Patient is aware of her health and up to date on her care. contradiction. Speech is clear and coherent. She maintains eye
contact throughout the interview.
General Survey
Ms. Jones is alert and oriented, seated upright on the examinatio
Patient looks healthy with no abnormality detected during inspection.
table, and is in no apparent distress. She is well-nourished, well-
Calm, not anxious, afebrile, anicteric, undertands and responds to
developed, and dressed appropriately with good hygiene.
questions appropriately. patient wears glasses for near sightedness.
Reason for Visit
"I came in because I'm required to have a recent physical exam
Patient is here for a complete health assessment for pre-employment
the health insurance at my new job."
physical.
, 4/25/2020 Week 4: Comprehensive Assessment | Completed | Shadow Health
Student Documentation Model Documentation
Ms. Jones reports that she recently obtained employment at Smi
Stevens, Stewart, Silver & Company. She needs to obtain a pre-
employment physical prior to initiating employment. Today she d
any acute concerns. Her last healthcare visit was 4 months ago,
History of Present Illness when she received her annual gynecological exam at Shadow H
General Clinic. Ms. Jones states that the gynecologist diagnosed
She is diabetic and glucose is well controlled.
with polycystic ovarian syndrome and prescribed oral contracept
Patient is also asthmatic and has PCOS
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 morni
Patient takes 850mg metformin twice daily, birth control pill - Yaz • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yester
every morning with breakfast and uses her inhaler not daily and not • Acetaminophen 500-1000 mg PO prn (headaches)
more that twice in a week • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6
weeks ago)
• Penicillin: rash
Allergies • Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to allergens she
Patient is allergic to cats, penicillins, dust
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 he
inhaler. She was last hospitalized for asthma in high school. Nev
intubated. Type 2 diabetes, diagnosed at age 24. She began
Medical History metformin 5 months ago and initially had some gastrointestinal s
effects which have since dissipated. She monitors her blood sug
Patient is diabetic and asthmatic. she uses medication in controlling once daily in the morning with average readings being around 90
her blood glucose. she was diagmosed of asthma when liitle and She has a history of hypertension which normalized when she
uses inhaler for the asthma. she also has PCOS which she takes the initiated diet and exercise. No surgeries. OB/GYN: Menarche, ag
birth control pill 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 month
(after initiating Yaz) cycles regular (every 4 weeks) with moderat
bleeding lasting 5 days. Has new male relationship, sexual conta
not initiated. She plans to use condoms with sexual activity. Test
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
Health Maintenance Immunizations: Tetanus booster was received within the past ye
influenza is not current, and human papillomavirus has been
Patient states she is eating healthier and trying really hard to stay
received. She reports that she believes she is up to date on child
active. she has been exercising, walks for thirty or forty minutes four
vaccines and received the meningococcal vaccine for college. S
or five times a week and also goes for swimming once a week
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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