NR 509 Tina Jones Comprehensive Health Assessment Documentation \/ Electronic Health Record:<\/p>\n
Documentation
\nVitals<\/p>\n
Height: 170 cm
\nWeight: 84 kg
\nBMI: 29.0
\nBlood Glucose: 100
\nRespiratory Rate (RR): 15
\nHeart Rate (HR): 78
\nBlood Pressure (BP): 128\/82
\nPulse Oximetry (Pulse Ox): 99%
\nTemperature: 99.0\u00b0F
\nHealth History
\nIdentifying Data & Reliability
\nMs. Jones is a pleasant 28-year-old African American female who presents to the clinic today for a physical for employment. Patient’s responses are appropriate, and she maintains eye contact throughout the exam.<\/p>\n
General Survey
\nPatient is in no apparent distress, alert and oriented x 4, calm and cooperative, appropriately dressed with good hygiene. 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.<\/p>\n
Reason for Visit
\nPatient states she needs an employment physical for a new job she will be beginning in two weeks. “I came in because I\u2019m required to have a recent physical exam for the health insurance at my new job.”<\/p>\n
History of Present Illness
\nPatient presents to the clinic for an employment physical that she will begin in two weeks. Patient denies any medical issues or concerns.<\/p>\n
Medications<\/p>\n
Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
\nAlbuterol 90 mcg 2 puffs PRN
\nMetformin 850mg PO BID
\nAdvil OTC regular strength PRN for cramps
\nYaz PO QD birth control
\nAllergies<\/p>\n
Penicillin: skin rash
\nMedical History<\/p>\n
Asthma diagnosed at age 2 1\/2.
\nHealth Maintenance
\nSince our last encounter…<\/p>\n
Last Pap smear 4 months ago.
\nLast eye exam was three months ago.
\nLast dental exam was five months ago.
\nFamily History<\/p>\n
Mother: age 50, hypertension, elevated cholesterol
\nFather: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes
\nBrother (Michael, 25): overweight
\nSister (Britney, 14): asthma
\nMaternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
\nMaternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol
\nPaternal grandmother: still living, age 82, hypertension
\nPaternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
\nPaternal uncle: alcoholism
\nNegative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems
\nSocial History<\/p>\n
Never married, no children.
\nCurrently in a relationship with a male.
\nDenies smoking or drug use.
\nOccasional alcohol with friends.
\nLikes to read.
\nCurrently lives at home with her mother and sister but has plans to move out next month.
\nMental Health History<\/p>\n
Denies any…
\nReview of Systems \u2013 General
\nGeneral: no weakness, fatigue, or fevers.
\nPositive weight loss of 10 pounds.
\nSkin: no rashes, lesions, dry skin, itching or color changes, no dandruff, or changes in nails.<\/p>\n
HEENT
\nSubjective
\nReports no current headache and no history of head injury or acute visual changes.<\/p>\n
Objective
\nNo obvious injuries or bruising.
\nHead is normocephalic.
\nBilateral eyes with equal hair distribution on lashes and eyebrows…<\/p>\n
Respiratory
\nSubjective
\nPatient denies shortness of breath, difficult breathing, wheezing, or cough. Patient has a history of asthma. Denies sinus pressure or rhinorrhea.<\/p>\n
Objective
\nPeak flow x3: …
\nChest is symmetric…<\/p>\n
Cardiovascular
\nSubjective
\nPatient denies chest pain, palpitations, or edema. No history of anemia or easy bruising.<\/p>\n
Objective
\nS1, S2 heard with normal rate and rhythm, no murmurs or gallops noted on auscultation…
\nHeart rate is regular, S1, S2, without murmurs, gallops, or rubs…<\/p>\n
Abdominal
\nSubjective
\nGastrointestinal: …<\/p>\n
Patient denies any nausea, vomiting, diarrhea, constipation, abdominal pain, or discomfort…<\/p>\n
Objective
\nAbdomen no visible bruising or lesions, protuberant,…
\nAbdomen protuberant,…<\/p>\n
Musculoskeletal
\nSubjective
\nPatient denies joint or muscle pain, weakness, or edema.
\nReports no muscle pain, joint pain, muscle weakness, or swelling.<\/p>\n
Objective
\nNo obvious injuries…
\nStrength 5\/5…<\/p>\n
Neurological
\nSubjective
\nPatient denies any numbness or tingling sensations,…
\nReports no dizziness,…<\/p>\n
Objective
\nGraphesthesia, stereognosis intact. Patient alert and oriented x 4,…
\nNormal graphesthesia,…<\/p>\n
Skin, Hair & Nails
\nSubjective
\nPatient denies rashes,…
\nReports improved acne due to…<\/p>\n
Objective
\nScattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck.
\nNails free…
\nNo obvious injuries, lacerations, rashes, dandruff, or bruising. Patient’s hair is well-groomed with even hair distribution. No nail deformities noted in all extremities, clear with no ridges. Excessive hair growth on umbilicus, thin hair growth on upper lip.<\/p>\n
Shadow Health Physical Assessment Rubric:<\/p>\n
Subjective Data, Organization, Communication, and Summary<\/p>\n
Above Average: Comprehensive introduction with expectations of the exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to the patient.
\nObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation<\/p>\n
Above Average: Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each component (diagnostics, medication, education, consultation\/referral, and follow-up planning).
\nSelf-Reflection<\/p>\n
Above Average: Responds to three of the three reflection post questions; provides analysis of performance; reflection posts written using professional language; reflection posts demonstrate insight.
\nDescription of criterion<\/p>\n","protected":false},"excerpt":{"rendered":"
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