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3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health

https://classroom.usuniversity.edu/d2l/le/content/61343/viewContent/3173533/View 1/6

Comprehensive Assessment (120 min minimum) Results | Turned In Advanced Physical Assessment Across the Lifespan (FNP) - USU - February 2021, msn572

Return to Assignment (/assignments/470720/)

Subjective Data Collection: 45 of 50 (90.0%)

Current Health Status

Your Results Lab Pass (/assignment_attempts/9539340/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Documentation

Plan My Exam

Indicates an item that you found. Indicates an item that is

available to be found.

Category Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of t patient's case.

Confirmed reason for visit Reports needing a pre-employment physical Reports no current acute health problems

Asked about last visit to a healthcare provider Last visit to a healthcare provider was 4 months ago Reason for last visit was annual gynecological

exam Last general physical examination was 5 months

ago when she was prescribed metformin and daily inhaler

Asked about current prescription medications Reports taking diabetes medication Reports using a daily inhaler Reports taking prescription birth control pills

Followed up about diabetes medication Medication is metformin Started taking metformin 5 months ago Reports that eating probiotic yogurt helps with

side effects and they have abated over time

Followed up on metformin frequency and dose Reports taking metformin twice daily Metformin dose is 850 mg

Asked about asthma medication Reports using Flovent inhaler twice daily Has a Proventil rescue inhaler Last use of Proventil inhaler was three months

ago Has used Proventil inhaler twice in the last year

Hover To Reveal...

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Support This study source was downloaded by 100000770473191 from CourseHero.com on 01-26-2022 21:45:20 GMT -06:00

https://www.coursehero.com/file/87550556/ShadowHealth-Final-Head-to-Toepdf/

3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health

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Followed up about birth control prescription Started taking birth control 4 months ago Reason for birth control was to manage PCOS

symptoms Birth control type is Yaz (drospirenone and ethinyl

estradiol) Takes birth control pill daily Takes birth control pill at the same time every day Reports no skipped days

Asked about current non-prescription medications

Reports rare Advil use for cramps Reports no OTC herbal products Reports no OTC vitamins Reports no OTC supplements

Asked about allergies Confirms allergies Reports no new allergies

Followed up on seasonal allergies Reports no recent seasonal allergy symptoms Reports no current medication for allergies

Asked about diabetes Reports managing diabetes with diet and exercise in addition to medication

Asked about blood glucose monitoring Reports checking blood sugar once a day Checks sugar in the morning Blood sugar number is usually around 90 Reports having adequate supplies

Asked about asthma symptoms Reports no current asthma symptoms Reports no recent asthma exacerbations Reports last asthma exacerbation was three

months ago

Asked about headache symptoms Reports no recent headache

Asked about vision Reports optometrist visit Optometrist visit 3 months ago Reports prescription eyeglasses Reports that glasses improve overall vision Reports reduction in blurry vision

Asked about palpitations Reports no current palpitations Reports no recent palpitations

Asked about hypertension treatment Reports that blood pressure responded to diet and exercise changes

Asked about GERD Reports no recent GERD symptoms Reports no current GERD symptoms Reports no current medication for GERD

Asked about back pain Reports no current back painThis study source was downloaded by 100000770473191 from CourseHero.com on 01-26-2022 21:45:20 GMT -06:00

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3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health

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Psychosocial History

Social Determinants of Health

Reports no recent back pain

Asked date of last menstrual period Last menstrual period was 2 weeks ago

Asked about menstrual patterns Reports a period every 4 weeks Reports that period lasts 5 days Reports some cramping Reports a medium flow

Asked about weight changes Reports recent weight loss Reports weight loss of about 10 pounds Reports that weight loss was result of change in

diet and increased exercise

Asked about diet Typical breakfast is fruit smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt Typical lunch is dinner leftovers or tuna or chicken

sandwich on wheat bread Typical dinner is vegetables with a protein and

brown rice or quinoa Typical snack is carrot sticks or an apple

Asked about caffeine intake Reports limiting caffeine since heart and sleep problems Reports no coffee drinking Reports only caffeine is diet Coke Reports drinking 2 diet Cokes per day

Asked about alcohol intake Drinks 2-3 nights per month Has 2 or 3 drinks when out with friends Orders single drinks Usually orders rum and diet Coke

Asked about exercise Reports mild to moderate exercise Reports walking four or five times a week Reports that a typical walk is thirty or forty

minutes Reports weekly swimming at YMCA Reports no asthma exacerbation during exercise

Asked about relationship status and current sexual activity

Reports no new sexual partners Reports new month-old relationship Plans to use condoms if sexually active in the

future

Asked about education Reports graduated with accounting degree

Asked about work Reports being hired at Smith, Stevens, Stewart, Silver & Company Reports job title is Accounting ClerkThis study source was downloaded by 100000770473191 from CourseHero.com on 01-26-2022 21:45:20 GMT -06:00

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3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health

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Mental Health

Review of Systems

Reports will start work in 2 weeks

Asked about living situation Reports currently living at home with mom and sister Reports moving into her own apartment near work

in 1 month

Asked about support system Reports strong friendships Reports strong familial relationships Reports church remains a strong support system

Asked about stress Reports feeling less stress after graduation and passing CPA exam Reports improved ability to cope with stress

Asked about indicators of depression Reports no depression Reports feeling positive about upcoming life

changes

Asked about anxiety Reports anxiety improved with relief of stressors and passing of time Reports coping well with upcoming life changes

Asked about sleep Reports no current difficulties falling asleep Reports sleeping 8 or 9 hours a night

Asked general indicators of health Reports no recent or frequent illness Reports no fatigue Reports no fever Reports no chills Reports no night sweats

Asked about review of systems for head Reports no current or recent head problems Reports no head injury

Asked about review of systems for ears Reports no general ear problems Reports no change in hearing Reports no ear pain Reports no ear discharge

Asked about review of systems for eyes Reports no eye pain Reports no itchy eyes Reports no eye redness Reports no dry eyes

Asked about review of systems for nose Reports no general nose problems Reports no change in sense of smell Reports no sneezing Reports no nosebleedsThis study source was downloaded by 100000770473191 from CourseHero.com on 01-26-2022 21:45:20 GMT -06:00

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3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health

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Reports no sinus pain Reports no sinus pressure Reports no runny nose

Asked about review of systems for mouth and jaw

Reports no current dental problems Reports last dental visit was 5 months ago Reports no general mouth problems Reports no change in sense of taste Reports no dry mouth Reports no mouth pain Reports no mouth sores Reports no gum problems Reports no tongue problems Reports no jaw problems

Asked about review of systems for neck and throat

Reports no difficulty swallowing Reports no sore throat Reports no history of throat problems Reports no voice changes Reports no general neck problems Reports no history of lymph node problems Reports no swollen glands

Asked about review of systems for respiratory Reports no current breathing problems Reports no wheezing Reports no chest tightness Reports no pain while breathing Reports no coughing

Asked about review of systems for cardiovascular

Reports no palpitations Reports no irregular heartbeat Reports no easy bruising Reports no edema Reports no circulation problems

Asked review of systems for gastrointestinal Reports no nausea Reports no vomiting Reports no stomach pain Reports no constipation Reports no diarrhea Reports no flatulence

Asked review of systems for genitourinary Reports no dysuria Reports reduction in nocturia Reports no polyuria Reports no blood in urine Reports no flank pain Reports no vaginal itching or irritation Reports normal vaginal discharge

Asked review of systems for breasts Reports no general breast problems Reports no breast lumps Reports no breast pain

Asked review of systems for musculoskeletal Reports no muscle pain Reports no joint pain

This study source was downloaded by 100000770473191 from CourseHero.com on 01-26-2022 21:45:20 GMT -06:00

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3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health

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Reports no muscle weakness Reports no muscle swelling

Asked review of systems for neurological Reports no dizziness or lightheadedness Reports no vision disturbance Reports no numbness or tingling Reports no loss of coordination Reports no loss of sensation Reports no seizures Reports no problems with balance

Asked review of systems for skin, hair and nails Reports no rashes Reports using sunscreen while exercising

outdoors Reports no recent slow-healing wounds Reports improving acne Reports some male-pattern hair growth Reports no changes in moles Reports no sores Reports no dandruff Reports no nail fungus Reports no dry skin

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