3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health
Comprehensive Assessment (120 min minimum) Results | Turned In
Advanced Physical Assessment Across the Lifespan (FNP) - USU - February 2021, msn572
Return to Assignment (/assignments/470720/)
Your Results Lab Pass (/assignment_attempts/9539340/lab_pass.pd
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Vitals
Documentation
Plan My Exam
Student Documentation Model Documentation
• Height: 170 cm
Vitals • Weight: 84 kg
• BMI: 29.0
BP 128/82
• Blood Glucose: 100
HR 78
• RR: 15
RR- 15
• HR: 78
Temp 37.2c
• BP:
O2: 99%
• 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
Tina Jones, 28yr old AA female, DOB 2/14, came to the clinic with
source of the history. Ms. Jones offers information freely and with
her mother for a physical for a new job. She appears to be a good
contradiction. Speech is clear and coherent. She maintains eye
historian and answers all questions appropriately.
contact throughout the interview.
General Survey
Patient is well dress, hygeine good with no odor, poster upright,
Ms. Jones is alert and oriented, seated upright on the examinatio
mobility is stable, attentive to all questios, attitude good with positive
table, and is in no apparent distress. She is well-nourished, well-
espressions. A&Ox4, very pleasant and cooperative. breathing is at
developed, and dressed appropriately with good hygiene.
ease. VS stable. eye exam 20/20 with snellan chart. HT, weight and
BMI charted. VS taken.
Reason for Visit
“I came in because I'm required to have a recent physical exam f
physical for new job the health insurance at my new job.”
Support
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, 3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health
Student Documentation Model Documentation
Ms. Jones reports that she recently obtained employment at Sm
History of Present Illness Stevens, Stewart, Silver & Company. She needs to obtain a pre-
employment physical prior to initiating employment. Today she
patient came in for a physical exam for a new job. no complaints of denies any acute concerns. Her last healthcare visit was 4 month
any current illnesses, patient states she has been feeling really good ago, when she received her annual gynecological exam at Shado
and healthy, exercising and eating well. Histroy Diabetes, asthma Health General Clinic. Ms. Jones states that the gynecologist
which she takes medications for and both are under control. diagnosed her with polycystic ovarian syndrome and prescribed
Last seen by a health care provider was 4 months ago for a GYN contraceptives at that visit, which she is tolerating well. She has
exam. Last physical exam was 5 months ago. Last eye exam 3 2 diabetes, which she is controlling with diet, exercise, and
months ago. metformin, which she just started 5 months ago. She has no
last dental cleaning 5 months ago. 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.
Medications • Fluticasone propionate, 110 mcg 2 puffs BID (last use: this
morning)
Metformin 850mg, BID, oral • Metformin, 850 mg PO BID (last use: this morning)
flovent-88mcg per spray, 2 puff, BID. • Drospirenone and ethinyl estradiol PO QD (last use: this mornin
proventil-90 mcg, 2 puffs, as needed • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three
Yaz-once daily with breakfast months ago)
Advil for cramping as needed • Acetaminophen 500-1000 mg PO prn (headaches)
denies any adverse reactions to medication • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6
weeks ago)
Allergies • Penicillin: rash
• Denies food and latex allergies
Penecillin
• Allergic to cats and dust. When she is exposed to allergens she
cats,
states that she has runny nose, itchy and swollen eyes, and
dust
increased asthma symptoms.
Medical History
Diabetes, Asthma well controlled with medications. Denise any Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler w
psychiatric problems, infectious diseases, surgeries or recent she is around cats. Her last asthma exacerbation was three mon
hospitalizations. She was last hospitalized in highschool for an ago, which she resolved with her inhaler. She was last hospitalize
asthma attach but has not had one since then. She is up to date on for asthma in high school. Never intubated. Type 2 diabetes,
all her childhood immunizations and has not taken the flu vaccine diagnosed at age 24. She began metformin 5 months ago and
this year. Educated patient on taking the flu vaccine. Last period was initially had some gastrointestinal side effects which have since
2 weeks ago and she is regular with her menstrual cycle after she dissipated. She monitors her blood sugar once daily in the morn
started birth control. She is in a relationship with a male but is not with average readings being around 90. She has a history of
sexually active. She has not been tested for STI's and does not plan hypertension which normalized when she initiated diet and exerc
on having babies soon. Tina does not preform breast examinations No surgeries. OB/GYN: Menarche, age 11. First sexual encounte
regularly nor has she had a mammogram. denies history of breast age 18, sex with men, identifies as heterosexual. Never pregnant
cancer. Last menstrual period 2 weeks ago. Diagnosed with PCOS four
months ago. For the past four months (after initiating Yaz) cycles
Last seen by a health care provider was 4 months ago for a GYN regular (every 4 weeks) with moderate bleeding lasting 5 days. H
exam. Last physical exam was 5 months ago. Last eye exam 3 new male relationship, sexual contact not initiated. She plans to
months ago. condoms with sexual activity. Tested negative for HIV/AIDS and S
last dental cleaning 5 months ago. four months ago.
Last pap smear 4 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.
Diabetes, asthma, Immunizations: Tetanus booster was received within the past yea
Last seen by a health care provider was 4 months ago for a GYN influenza is not current, and human papillomavirus has not been
exam. Last physical exam was 5 months ago. Last eye exam 3 received. She reports that she believes she is up to date on
months ago. childhood vaccines and received the meningococcal vaccine for
last dental cleaning 5 months ago. college. Safety: Has smoke detectors in the home, wears seatbe
last pap smear 4 months ago car, and does not ride a bike. Uses sunscreen. Guns, having
belonged to her dad, are in the home, locked in parent’s room.
This study source was downloaded by 100000850299972 from CourseHero.com on 08-22-2022 13:03:01 GMT -05:00
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Comprehensive Assessment (120 min minimum) Results | Turned In
Advanced Physical Assessment Across the Lifespan (FNP) - USU - February 2021, msn572
Return to Assignment (/assignments/470720/)
Your Results Lab Pass (/assignment_attempts/9539340/lab_pass.pd
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Vitals
Documentation
Plan My Exam
Student Documentation Model Documentation
• Height: 170 cm
Vitals • Weight: 84 kg
• BMI: 29.0
BP 128/82
• Blood Glucose: 100
HR 78
• RR: 15
RR- 15
• HR: 78
Temp 37.2c
• BP:
O2: 99%
• 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
Tina Jones, 28yr old AA female, DOB 2/14, came to the clinic with
source of the history. Ms. Jones offers information freely and with
her mother for a physical for a new job. She appears to be a good
contradiction. Speech is clear and coherent. She maintains eye
historian and answers all questions appropriately.
contact throughout the interview.
General Survey
Patient is well dress, hygeine good with no odor, poster upright,
Ms. Jones is alert and oriented, seated upright on the examinatio
mobility is stable, attentive to all questios, attitude good with positive
table, and is in no apparent distress. She is well-nourished, well-
espressions. A&Ox4, very pleasant and cooperative. breathing is at
developed, and dressed appropriately with good hygiene.
ease. VS stable. eye exam 20/20 with snellan chart. HT, weight and
BMI charted. VS taken.
Reason for Visit
“I came in because I'm required to have a recent physical exam f
physical for new job the health insurance at my new job.”
Support
This study source was downloaded by 100000850299972 from CourseHero.com on 08-22-2022 13:03:01 GMT -05:00
https://classroom.usuniversity.edu/d2l/le/content/61343/viewContent/3173533/View 1/6
https://www.coursehero.com/file/87550682/ShadowHealth-Advanced-Health-and-Physical-Assessment-Across-The-Lifespan-A-YL-03-02-21-Sect8/
, 3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health
Student Documentation Model Documentation
Ms. Jones reports that she recently obtained employment at Sm
History of Present Illness Stevens, Stewart, Silver & Company. She needs to obtain a pre-
employment physical prior to initiating employment. Today she
patient came in for a physical exam for a new job. no complaints of denies any acute concerns. Her last healthcare visit was 4 month
any current illnesses, patient states she has been feeling really good ago, when she received her annual gynecological exam at Shado
and healthy, exercising and eating well. Histroy Diabetes, asthma Health General Clinic. Ms. Jones states that the gynecologist
which she takes medications for and both are under control. diagnosed her with polycystic ovarian syndrome and prescribed
Last seen by a health care provider was 4 months ago for a GYN contraceptives at that visit, which she is tolerating well. She has
exam. Last physical exam was 5 months ago. Last eye exam 3 2 diabetes, which she is controlling with diet, exercise, and
months ago. metformin, which she just started 5 months ago. She has no
last dental cleaning 5 months ago. 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.
Medications • Fluticasone propionate, 110 mcg 2 puffs BID (last use: this
morning)
Metformin 850mg, BID, oral • Metformin, 850 mg PO BID (last use: this morning)
flovent-88mcg per spray, 2 puff, BID. • Drospirenone and ethinyl estradiol PO QD (last use: this mornin
proventil-90 mcg, 2 puffs, as needed • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three
Yaz-once daily with breakfast months ago)
Advil for cramping as needed • Acetaminophen 500-1000 mg PO prn (headaches)
denies any adverse reactions to medication • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6
weeks ago)
Allergies • Penicillin: rash
• Denies food and latex allergies
Penecillin
• Allergic to cats and dust. When she is exposed to allergens she
cats,
states that she has runny nose, itchy and swollen eyes, and
dust
increased asthma symptoms.
Medical History
Diabetes, Asthma well controlled with medications. Denise any Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler w
psychiatric problems, infectious diseases, surgeries or recent she is around cats. Her last asthma exacerbation was three mon
hospitalizations. She was last hospitalized in highschool for an ago, which she resolved with her inhaler. She was last hospitalize
asthma attach but has not had one since then. She is up to date on for asthma in high school. Never intubated. Type 2 diabetes,
all her childhood immunizations and has not taken the flu vaccine diagnosed at age 24. She began metformin 5 months ago and
this year. Educated patient on taking the flu vaccine. Last period was initially had some gastrointestinal side effects which have since
2 weeks ago and she is regular with her menstrual cycle after she dissipated. She monitors her blood sugar once daily in the morn
started birth control. She is in a relationship with a male but is not with average readings being around 90. She has a history of
sexually active. She has not been tested for STI's and does not plan hypertension which normalized when she initiated diet and exerc
on having babies soon. Tina does not preform breast examinations No surgeries. OB/GYN: Menarche, age 11. First sexual encounte
regularly nor has she had a mammogram. denies history of breast age 18, sex with men, identifies as heterosexual. Never pregnant
cancer. Last menstrual period 2 weeks ago. Diagnosed with PCOS four
months ago. For the past four months (after initiating Yaz) cycles
Last seen by a health care provider was 4 months ago for a GYN regular (every 4 weeks) with moderate bleeding lasting 5 days. H
exam. Last physical exam was 5 months ago. Last eye exam 3 new male relationship, sexual contact not initiated. She plans to
months ago. condoms with sexual activity. Tested negative for HIV/AIDS and S
last dental cleaning 5 months ago. four months ago.
Last pap smear 4 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.
Diabetes, asthma, Immunizations: Tetanus booster was received within the past yea
Last seen by a health care provider was 4 months ago for a GYN influenza is not current, and human papillomavirus has not been
exam. Last physical exam was 5 months ago. Last eye exam 3 received. She reports that she believes she is up to date on
months ago. childhood vaccines and received the meningococcal vaccine for
last dental cleaning 5 months ago. college. Safety: Has smoke detectors in the home, wears seatbe
last pap smear 4 months ago car, and does not ride a bike. Uses sunscreen. Guns, having
belonged to her dad, are in the home, locked in parent’s room.
This study source was downloaded by 100000850299972 from CourseHero.com on 08-22-2022 13:03:01 GMT -05:00
https://classroom.usuniversity.edu/d2l/le/content/61343/viewContent/3173533/View 2/6
https://www.coursehero.com/file/87550682/ShadowHealth-Advanced-Health-and-Physical-Assessment-Across-The-Lifespan-A-YL-03-02-21-Sect8/
