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Tina jones comprehensive
Advanced Health Assessment (NURS 6512)
Walden University
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Comprehensive Assessment Results | Turned In
Health Assessment for the BSN - Muskegon - Spring 2019, NUR 2250
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Your Results Lab Pass Lab Pass
Documentation
Vitals
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Vitals
BP: 142/82; HR: 68; RR: 16; O2: 98%; Temperature: 37 C
- Height: 170 cm
- Weight: 84 kg
- BMI: 29.
- Blood Glucose: 100
- RR: 15
- HR: 78
- BP:128 / 82
- Pulse Ox: 99%
- Temperature: 99 F
Health History
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Identifying Data & Reliability
Patient is in no apparent distress. Alert and oriented x4. Patient is seated upright on the examination table, she is well nourished, and dressed appropriately for the weather with good hygiene.
Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre- employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Documentation
Plan My Exam
Documentation / Electronic Health Record
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General Survey
Tina Jones is a pleasant 28 year old African American woman who presents for pre-employment physical. She offers information freely and without contradiction. Beach is clear and coherent and maintains eye contact throughout the interview. Patient denies any current pain.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Reason for Visit
"I came in because I'm required to have a recent physical examination for the health insurance at my new job"
"I came in because I'm required to have a recent physical exam for the health insurance at my new job."
History of Present Illness
Denies any pain or present illness.
Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that 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.
Medications
Metformin QD, Yaz QD, Inhaler PRN, "never more than twice a week, sometimes not at all"
- Metformin, 850 mg PO BID (last use: this morning)
- Drospirenone and ethinyl estradiol PO QD (last use: this morning)
- Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yesterday)
- Acetaminophen 500-1000 mg PO prn (headaches)
- Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)
Allergies
Penicillin; rash/ hives.
- Penicillin: rash
- Denies food and latex allergies
- Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.
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Social History
Patient drinks alcohol about six drinks per month socially with friends. Patient denies drug use.
Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.
Mental Health History
Patient denies any concerns with mental health. Patient does have slight anxiety, congruent with sleep problems, only lasted for a couple weeks, patient self treated by attending church, and talking with specialist.
Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear.
Review of Systems - General
Reports 10 pound weight loss in the last 4 months due to exercise. Denies fatigue, fever, chills, or night sweats.
No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase.
HEENT
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Subjective
Patient denies any Vision change, good start wearing glasses 3 months ago. Reports no eye pain, itchy eyes redness or dry eyes. Patient denies any changes in hearing your pain or discharge. Patient reports no change in sense of smell sneezing for sinus pressure. Patient reports no General mouth problems or change in taste.
Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.
Objective
Head is normal cephalic atraumatic. Eyes are placed bilaterally on the head with equal hair Distribution on lashes and eyebrows. No ptosis or edema noted. Conjunctiva pink no lesions white sclera. Eyes are PERRLA. Eyes are intact bilaterally no nystagmus is present. Snellen 20/20 bilaterally. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink septum midline. Oral mucosa moist and without lesions. Tonsils present. No goiter noted.
Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.
Respiratory
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Subjective
Patient denies shortness of breath wheezing chest pain dyspnea or cough.
Reports no current breathing problems. Reports occasional shortness of breath, wheezing, and chest tightness.
Objective
Chastise symmetric with respiration clear to auscultation bilaterally without cough or wheeze. FVC 3 L; FEV1: 3. Tactile fremitus present. Palpating thoracic expansion symmetric.
Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3 L, FEV1/FVC ratio 80%.
Cardiovascular
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Subjective
Patient denies any dizziness lightheadedness tingling loss of coordination no seizures.
Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.
Objective
Normal graphesthesia, sterognosis, and able to make rapid movements bilaterally. Decreased sensation to monofilament in bilateral plantar surfaces.
Strength 5/5 bilateral upper and lower extremities. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.
Skin, Hair & Nails
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Subjective
Patient reports an improve in acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports I feel moles but no other hair or nail changes.
Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.
Objective
No obvious injuries lacerations rashes dandruff or bruising. Patience hair is well-groomed with even distribution. No nail deformities. Scattered pustules on face and facial hair on upper lip.
Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck.
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Tina jones comprehensive
Course: Advanced Health Assessment (NURS 6512)
University: Walden University
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