NRNP 6531 Week 9 - Comprehensive Assessment, Tina Jones - REQUIRED | Completed | Shadow Health

Documentation / Electronic Health Record Vitals Student Documentation Model Documentation Vitals Initials: T.J. Age: 28 Race: B Gender: F VS: T 37.2 (oral) BP 128/82 (manual) P 78 RR 15 O2 99% (RA) Ht. 5'7" (stated) Wt. 198.41 (standing scale) Spirometer 1.78/1.549 N/A Health History Student Documentation Model Documentation Identifying Data & Reliability Miss Jones is a 28 y/o BF who presents to the clinic for a preemployment physical. She is polite, cooperative, and speech is clear and appropriate to context. Makes appropriate eye contact. Miss Jones is unaccompanied for this visit. She is the primary source of data collection and is a reliable historian for this exam. N/A General Survey Miss Jones is a well-dressed, polite, moderately obese female. She is AAO x 3. She answers questions appropriately and appears to be in no acute distress or discomfort. Her VS are stable and she denies current pain or distress. N/A Reason for Visit The patient presents to the clinic for a pre-employment physical exam. N/A Your Results Reopen (/assignment_attempts//reopen Lab Pass (/assignment_attempts//lab_pass.p Overview Transcript Subjective Data Collection Objective Data Collection Documentation Program Competency Progress Documentation Support This study source was downloaded by from CourseH on :19:29 GMT -05:00 5/2/2021 Week 9 - Comprehensive Assessment, Tina Jones - REQUIRED | Completed | Shadow Health Student Documentation Model Documentation History of Present Illness Patient presents to the clinic requesting physical exam for new job. She states she is in good health and was recently diagnosed with PCOS. N/A Medications Metformin 850 mg po one tab twice daily for DM Flovent two puffs twice daily for asthma Proventil two puffs prn for asthma Yaz (drosperenone/ethinyl estradiol) one tab by mouth daily for birth control. (Patient does not know dosage) Advil (OTC) prn for cramps (denies knowing dosage) N/A Allergies Penicillin-rash Cats-causes sneezing