HA33

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Week_9_Documentation_Notes_for_Assignment_3_DCE.docx1.pdf

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Name:

Comprehensive Assessment

Vitals

Health History

Identifying Data

Geneva Addison

Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. When you are ready to submit your documentation, ‘Save As’ with this title format: “[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512”

BP- 128/82, HR 78, RR 15, O2 99%, Temp. 99.0F, Ht. 170cm, Wt. 84kg, BMI 29, Blood sugar 100

Tina Jones is a 28-year-old AA female who presents to the clinic today for a pre-employment physical. Ms. Jones is the primary historian for this interview.

Document: Provider Notes – NURS 6512

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General Survey

Patient is alert and oriented x4, sitting on examination table in no acute distress, seems well groomed and nourished, dressed appropriate for the weather, speech is clear and coherent, no disorganized thought process noted, patient is pleasant and cooperative.

Document: Provider Notes – NURS 6512

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Reason for Visit

Physical examination for pre-employment at new job.

Tina Jones is a 28-year-old AA female who presents to the clinic today for a pre-employment physical for a job she recently obtained at Smith, Stevens, Steward, Silver & Company. Patient denies any complaints at present and reports feeling healthy since making changes to her diet and exercising. She reports her last primary care visit was about 5 months ago. Her current medical conditions are well controlled with diet, exercise, and medication.

Document: Provider Notes – NURS 6512

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History of Present Illness

Medications

Metformin 850mg 1 tablet by mouth twice daily started 5 months ago

Advil 200mg (2tabs) by mouth as needed for cramps

Albuterol inhaler 90 mcg/spray, 2 puffs as needed

Flovent inhaler 88 mcg/spray, 2 puffs twice daily

Drospirenone/ ethinyl estradiol 1 tablet by mouth daily with breakfast

Zantac no longer taking for heartburn

Document: Provider Notes – NURS 6512

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Allergies

Penicillin- Rash/Hives

Cats- asthma flare up

Dust- trigger asthma attack

Type 2 Diabetes diagnosed at age 24

Asthma diagnosed as a child at age 2 1/2

Menstrual cramps with onset of menstrual cycle at age 11

Headaches started 6 months ago from studying a lot and straining her eyes in the process

GERD diagnosed a few months ago

PCOS diagnosed about 4 months ago

Near sighted diagnosed 3 months ago and prescribed eye glasses and to return in 1 year for a checkup.

Reports immunizations up-to-date, denies flu vaccine this season, last flu vaccine 5-6 years ago, received Tetanus vaccine 1 year ago, can’t recall last pneumonia vaccine. Reports having chicken pox as a child in 2nd or 3rd grade.

No Surgical History

Document: Provider Notes – NURS 6512

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Medical History

Health Maintenance

Family History

Document: Provider Notes – NURS 6512

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Social History

Father died at age 58 from MVA. Mother has high blood pressure and high cholesterol, age 50. Sister has asthma, age 15. Brother is obese with no other health problems, age 26. Maternal grandmother died at age 73 had a history of stroke and high blood pressure and high cholesterol. Paternal grandmother still living with high blood pressure and high cholesterol at the age of 82. Paternal grandfather died of colon cancer in his mid-60s. Maternal grandfather died at 80 he had high blood pressure and high cholesterol.

Social History

Patient reports hanging out with friends occasionally and consumes two to three beers in one sitting two or three times a month. Rum and diet coke is her drink of choice. She usually drinks 2 diet cokes a day always before 1pm and never after 3 or 4. Denies drinking coffee due to the bitter taste. Denies smoking tobacco, reports smoking marijuana in high school and after high school, stopped smoking marijuana at the age of 21. Denies current use of illicit drugs. Reports dating but not currently sexually active but reports will use condom when the time comes. Patient identifies as a heterosexual. Patient recently graduated with an Accountant degree where she will be working at Smith, Stevens, Stewart, Silver & Company as an Accountant clerk in about two weeks. Patient is currently living with her mother and sister but is planning on moving out in a month into an apartment that is closer to her new job. She reports using a seatbelt when driving. Volunteers at Habitat for Humanity with church family monthly. Hobbies are reading books with book club, going out with friends and church family and watching television. She relies on her family, friends, and church family for emotional support.

Patient walks for 30-40 minutes a day, four to five days a week and she swim at the YMCA with her friend once a week. Patient eats three balance meals a day. For breakfast she has an egg and wheat toast with yogurt or a smoothie instead. For lunch she will have something leftover from dinner or make something new like black beans with roasted butternut squash, quinoa, or brown rice. Or she may have tuna with olive oil, onion, and cucumber chopped up in it and have that on wheat bread. Or she may have a wheat wrap with chicken, spinach, tomato, and feta cheese. For dinner she will have roasted chicken or salmon with brown rice or quinoa with roasted vegetables. Reports having two primary care visits this year.

Document: Provider Notes – NURS 6512

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Mental Health History

Patient denies having anxiety or depression, she denies ever having suicidal thoughts or trying to harm herself. She reports talking to friends about problems and trying to deal with them as they come up instead of keeping everything inside. Speaking to someone here at the clinic has seem to help when she was having sleeping problems a couple of weeks ago. She also relies on her faith and church family when things seem difficulty.

Document: Provider Notes – NURS 6512

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General- Patient denies fever, chills, night sweats, or fatigue. Reports losing 10lbs in the past 4 months due to diet change and exercise.

Head- Denies head injury, reports having headaches while studying but headaches has improved since being prescribed glasses.

Eyes- Denies eye pain, itching, drainage or dryness to eyes. Reports being prescribed eye glasses.

Ears- Denies ear pain or drainage. Denies hearing issues.

Nose- Denies nasal congestion, nasal drainage, nasal pain, sneezing, loss of smell, sinus pressure, runny nose, or nose bleeds.

Mouth/Throat- Denies mouth sores, hoarseness, change in voice, sore throat, bleeding or swelling gums, change in taste, or dental carries.

Neck- Denies lumps or masses to neck, denies swollen lymph nodes, denies injury to neck or swollen glands.

Cardiac- Denies chest pains, chest pressure, palpitations, or dysrhythmias. Denies heart attack. Reports blood pressure being high at previous visits, however, the last reading at the gynecologist office was normal.

Respiratory- Denies difficulty breathing, wheezing, dyspnea on exertion, or new or worsen cough. Reports history of asthma that is controlled with inhalers and avoidance of triggers.

Breast- Denies having breast issues. Denies breast pains, discharge, or lumps noted to breast. Denies having a mammogram.

GI- Denies nausea/vomiting, constipation or diarrhea. Denies stomach pains, change in stool color or contents. Denies dysphagia, flatulence, or hemorrhoids. Reports having a history of heart burn, however, heartburn has gotten better since starting birth control medication.

GU- Denies dysuria, hematuria, polyuria, or nocturia. Denies vaginal discharge or itching. Denies history of STD’s or flank pain. Reports LMP 2 weeks ago, cycles lasting 5 days with a medium flow. Reports cycles being normal monthly. Reports having cramps with cycle, however, since starting birth control medications cramps have gotten better.

Hematologic/Peripheral vascular- Denies anemia or any blood disorder. Denies claudication, swelling to upper or lower extremities, denies bruising or bleeding easily, denies history of blood clots. Denies open cuts, sores, or wound to body. Reports mole to right upper back has not changed in appearance. Denies slow wound healing. Reports using sunscreen when in direct sunlight. Reports increase to facial hair and abdominal hair. Reports dry skin but use lotions to help.

Musculoskeletal- Denies joint stiffness, muscle pain, weakness, or swelling.

Neuro- Denies syncope, seizures, dizziness, vertigo, or light headedness. Denies numbness, tingling, or loss of sensation.

Mental health- Denies anxiety, depression, suicidal thoughts, or attempting to hurt herself. Denies difficulty concentrating, nervousness, or irritability. Reports having sleep problems in the past but sleeps 8-9 hours nightly currently.

Document: Provider Notes – NURS 6512

Review of Systems – General (Subjective)

Document: Provider Notes – NURS 6512

Vital Signs: BP- 128/82, HR 78, RR 15, O2 99%, Temp. 99.0F, Ht. 170cm, Wt. 84kg, BMI 29, Blood sugar 100

General- Ms. Jones is alert and oriented x4, sitting on examination table in no acute distress. Patient is well groomed and nourished. Dressed appropriate for the weather, speech is coherent, keeps eye contact throughout interview.

Head- symmetrical in appearance, scalp is clear of dandruff, no sores noted to head.

Eyes- PERRLA, EOM, visual acuity, 20/20 vision, sclera white, no redness, drainage, or watery eyes noted at present.

Ears- Bilateral tympanic membranes pearly gray and intact. Positive light reflexes. No cerumen build-up noted. Hearing intact.

Nose- No deviated septum. No nasal polyps, bilateral nasal passage patent, no nasal tenderness or swelling upon palpation.

Mouth/Throat- Oral mucosa moist, no sores or lesions noted to mouth, Uvula midline, normal size tonsils, no dental carries present, gag reflex intact.

Lymphatic/Neck- No deviated trachea, normal size thyroid, no masses or lumps noted to neck, no tenderness or bruits noted.

Cardiovascular- Regular rate and rhythm S1S2, no murmur, rub, or gallop present. No carotid bruit present. No swelling noted to upper or lower extremities, capillary refill less than 3 seconds to finger and toes. Bilateral 2+ carotid, brachial, radial, femoral, popliteal, pedal, and post-tibial pulses.

Respiratory- Respirations even and unlabored, breath sounds clear to auscultation in all lung bases. No adventitious breath sounds noted. Muffled voice sounds noted in all lung fields upon auscultation. Spirometer reading, FVC 1.78L, FEV1 1.549L. Oxygen level 99% on room air.

Abdomen- Soft, non-tender, and protuberant in appearance. Bowel sounds normoactive in all quadrants. No hepatomegaly or splenomegaly noted. Liver span 7cm, no tenderness, pain or palpable masses noted to abdomen.

Musculoskeletal- Full range of motion to neck, upper, and lower extremities. Bilateral 5/5 strength to hands, arms, legs and feet. Normal spinal curvature. No deformities or masses noted.

Neurovascular- Alert and oriented x4, normal gait, sensation intact, pass stereognosis test, patient identified a key, paper clip, and a coin.

Diagnostics:

CBC, BMP, A1C, Lipid panel, Drug screen, EKG, CXR

Assessment:

1. Encounter for pre-employment examination

2. Encounter for examination for insurance purposes

3. Type 2 diabetes (pre-existing)

4. PCOS (pre-existing)

5. Asthma (pre-existing)

Document: Provider Notes – NURS 6512

Objective

Document: Provider Notes – NURS 6512