7/20/2020 Comprehensive Assessment - Part 1 | Completed | Shadow Health
Comprehensive Assessment - Part 1 Results | Turned In
Health Assessment RN to BSN - August 2015, NURS 360
Return to Assignment (/assignments/47845/)
Your Results Lab Pass (/assignment_attempts/703995/lab_pass.p
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation Vitals
Objective Data Collection
Vitals
Documentation
Plan My Exam
Student Documentation Model Documentation
Self-Reflection • Height: 170 cm
• Weight: 84 kg
• BMI: 29.0
• Blood Glucose: 100
(No Documentation Made) • RR: 15
• HR: 78
• BP:
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
28 year old female from Shadowville, arrived alone for a physical
exam for health insurance at her new job. Patient is single, black
American, speaks and wites english Fluently, has a BA in accointing,
no kids, leaves at home with mother and is moving to own place
soon. Patient is allergic to Penicillin, reports hives as a reaction to
penicillin. Also allergic to cats and dust, which make her wheeze,
sneeze, and trigger asthma attack. reports many hospitalizations as a
kid for asthma, but has not had any recent asthma attack. Patient
takes proventil for her asthma, 2 puffs. patient is currently taking Ms. Jones is a pleasant, 28-year-old African American single wo
metforming 800mg twice day for diabetes anf states that her blood who presents for a pre-employment physical. She is the primary
sugar level has been fine. Patient checks her blood glucose level evry source of the history. Ms. Jones offers information freely and with
day, once/day. Patient is on Yaz, birth control pill once/day. patient contradiction. Speech is clear and coherent. She maintains eye
report being up to date with her childhood immunizations, has had a contact throughout the interview.
tetanus booster one year ago, hae not has any pneumonia shot and
influenxa shot. had a tuberculosis test a couple of years ago ans was
ok. patient takes alcohol occasionally, a couple of time per month with
friends; denies smoking, had taken Pot before and has stopped.
resident denies being under stress, stated that she is eating healthier
now, is sleeping well and has a lot of energy. denies being in pain.
denies eating sweets, stated that she eats whole grain and
vegetables. Dad's brother had alcohol problem. patient is currently
dating, but not sexually active.
Support
This study source was downloaded by 100000840862941 from CourseHero.com on 02-17-2022 11:23:37 GMT -06:00
https://chamberlain.shadowhealth.com/assignment_attempts/703995 1/6
https://www.coursehero.com/file/65634992/Comprehensive-Assessment-Part-1-Completed-Shadow-Healthpdf/
, 7/20/2020 Comprehensive Assessment - Part 1 | Completed | Shadow Health
Student Documentation Model Documentation
Ms. Jones is alert and oriented, seated upright on the examinatio
General Survey
table, and is in no apparent distress. She is well-nourished, well-
28 year old black American. Single, lives at home with mother, works.
developed, and dressed appropriately with good hygiene.
Reason for Visit "I came in because I'm required to have a recent physical exam f
here for physical examination for health insurance at new job. the health insurance at my new job."
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 de
any acute concerns. Her last healthcare visit was 4 months ago,
when she received her annual gynecological exam at Shadow He
History of Present Illness
General Clinic. Ms. Jones states that the gynecologist diagnosed
had diabetes type 2, diagnosed at 24. has asthma, diagnosed at 2
with polycystic ovarian syndrome and prescribed oral contracept
and half year old.
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.
• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this mor
• Metformin, 850 mg PO BID (last use: this morning)
Medications
• Drospirenone and ethinyl estradiol PO QD (last use: this mornin
metformin 850 every day,
• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three mo
flovent 2 puff bid as needed.
ago)
Yaz once/day
• Acetaminophen 500-1000 mg PO prn (headaches)
• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6
weeks ago)
• Penicillin: rash
Allergies
• Denies food and latex allergies
Penicillin, had hives,
• Allergic to cats and dust. When she is exposed to allergens she
cat, sneezes and wheeze
states that she has runny nose, itchy and swollen eyes, and
dust, sneezes and wheeze
increased asthma symptoms.
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler w
she is around cats. Her last asthma exacerbation was three mon
ago, which she resolved with her inhaler. She was last hospitalize
for asthma in high school. Never intubated. Type 2 diabetes,
diagnosed at age 24. She began metformin 5 months ago and in
had some gastrointestinal side effects which have since dissipate
She monitors her blood sugar once daily in the morning with ave
Medical History readings being around 90. She has a history of hypertension whi
Asthma, diabetes. normalized when she initiated diet and exercise. No surgeries.
OB/GYN: Menarche, age 11. First sexual encounter at age 18, se
with men, identifies as heterosexual. Never pregnant. Last mens
period 2 weeks ago. Diagnosed with PCOS four months ago. Fo
past four months (after initiating Yaz) cycles regular (every 4 wee
with moderate bleeding lasting 5 days. Has new male relationshi
sexual contact not initiated. She plans to use condoms with sexu
activity. Tested 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
Health Maintenance
influenza is not current, and human papillomavirus has not been
was in the hospital a month ago, saw eye Dr three months ago, last
received. She reports that she believes she is up to date on child
gynecology exam four yeas ago, occasionally perform breast self
vaccines and received the meningococcal vaccine for college. Sa
exam, never had a mammogram, last dental exam five months ago,
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.
Support
This study source was downloaded by 100000840862941 from CourseHero.com on 02-17-2022 11:23:37 GMT -06:00
https://chamberlain.shadowhealth.com/assignment_attempts/703995 2/6
https://www.coursehero.com/file/65634992/Comprehensive-Assessment-Part-1-Completed-Shadow-Healthpdf/
Comprehensive Assessment - Part 1 Results | Turned In
Health Assessment RN to BSN - August 2015, NURS 360
Return to Assignment (/assignments/47845/)
Your Results Lab Pass (/assignment_attempts/703995/lab_pass.p
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation Vitals
Objective Data Collection
Vitals
Documentation
Plan My Exam
Student Documentation Model Documentation
Self-Reflection • Height: 170 cm
• Weight: 84 kg
• BMI: 29.0
• Blood Glucose: 100
(No Documentation Made) • RR: 15
• HR: 78
• BP:
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
28 year old female from Shadowville, arrived alone for a physical
exam for health insurance at her new job. Patient is single, black
American, speaks and wites english Fluently, has a BA in accointing,
no kids, leaves at home with mother and is moving to own place
soon. Patient is allergic to Penicillin, reports hives as a reaction to
penicillin. Also allergic to cats and dust, which make her wheeze,
sneeze, and trigger asthma attack. reports many hospitalizations as a
kid for asthma, but has not had any recent asthma attack. Patient
takes proventil for her asthma, 2 puffs. patient is currently taking Ms. Jones is a pleasant, 28-year-old African American single wo
metforming 800mg twice day for diabetes anf states that her blood who presents for a pre-employment physical. She is the primary
sugar level has been fine. Patient checks her blood glucose level evry source of the history. Ms. Jones offers information freely and with
day, once/day. Patient is on Yaz, birth control pill once/day. patient contradiction. Speech is clear and coherent. She maintains eye
report being up to date with her childhood immunizations, has had a contact throughout the interview.
tetanus booster one year ago, hae not has any pneumonia shot and
influenxa shot. had a tuberculosis test a couple of years ago ans was
ok. patient takes alcohol occasionally, a couple of time per month with
friends; denies smoking, had taken Pot before and has stopped.
resident denies being under stress, stated that she is eating healthier
now, is sleeping well and has a lot of energy. denies being in pain.
denies eating sweets, stated that she eats whole grain and
vegetables. Dad's brother had alcohol problem. patient is currently
dating, but not sexually active.
Support
This study source was downloaded by 100000840862941 from CourseHero.com on 02-17-2022 11:23:37 GMT -06:00
https://chamberlain.shadowhealth.com/assignment_attempts/703995 1/6
https://www.coursehero.com/file/65634992/Comprehensive-Assessment-Part-1-Completed-Shadow-Healthpdf/
, 7/20/2020 Comprehensive Assessment - Part 1 | Completed | Shadow Health
Student Documentation Model Documentation
Ms. Jones is alert and oriented, seated upright on the examinatio
General Survey
table, and is in no apparent distress. She is well-nourished, well-
28 year old black American. Single, lives at home with mother, works.
developed, and dressed appropriately with good hygiene.
Reason for Visit "I came in because I'm required to have a recent physical exam f
here for physical examination for health insurance at new job. the health insurance at my new job."
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 de
any acute concerns. Her last healthcare visit was 4 months ago,
when she received her annual gynecological exam at Shadow He
History of Present Illness
General Clinic. Ms. Jones states that the gynecologist diagnosed
had diabetes type 2, diagnosed at 24. has asthma, diagnosed at 2
with polycystic ovarian syndrome and prescribed oral contracept
and half year old.
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.
• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this mor
• Metformin, 850 mg PO BID (last use: this morning)
Medications
• Drospirenone and ethinyl estradiol PO QD (last use: this mornin
metformin 850 every day,
• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three mo
flovent 2 puff bid as needed.
ago)
Yaz once/day
• Acetaminophen 500-1000 mg PO prn (headaches)
• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6
weeks ago)
• Penicillin: rash
Allergies
• Denies food and latex allergies
Penicillin, had hives,
• Allergic to cats and dust. When she is exposed to allergens she
cat, sneezes and wheeze
states that she has runny nose, itchy and swollen eyes, and
dust, sneezes and wheeze
increased asthma symptoms.
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler w
she is around cats. Her last asthma exacerbation was three mon
ago, which she resolved with her inhaler. She was last hospitalize
for asthma in high school. Never intubated. Type 2 diabetes,
diagnosed at age 24. She began metformin 5 months ago and in
had some gastrointestinal side effects which have since dissipate
She monitors her blood sugar once daily in the morning with ave
Medical History readings being around 90. She has a history of hypertension whi
Asthma, diabetes. normalized when she initiated diet and exercise. No surgeries.
OB/GYN: Menarche, age 11. First sexual encounter at age 18, se
with men, identifies as heterosexual. Never pregnant. Last mens
period 2 weeks ago. Diagnosed with PCOS four months ago. Fo
past four months (after initiating Yaz) cycles regular (every 4 wee
with moderate bleeding lasting 5 days. Has new male relationshi
sexual contact not initiated. She plans to use condoms with sexu
activity. Tested 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
Health Maintenance
influenza is not current, and human papillomavirus has not been
was in the hospital a month ago, saw eye Dr three months ago, last
received. She reports that she believes she is up to date on child
gynecology exam four yeas ago, occasionally perform breast self
vaccines and received the meningococcal vaccine for college. Sa
exam, never had a mammogram, last dental exam five months ago,
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.
Support
This study source was downloaded by 100000840862941 from CourseHero.com on 02-17-2022 11:23:37 GMT -06:00
https://chamberlain.shadowhealth.com/assignment_attempts/703995 2/6
https://www.coursehero.com/file/65634992/Comprehensive-Assessment-Part-1-Completed-Shadow-Healthpdf/
