2/25/2021 Comprehensive Assessment | Completed | Shadow Health

Shadow Health will be undergoing scheduled maintenance on February 26th, 2021 between 07:00 AM ET and 07:30 AM (/site_notice_dismissals?from_flash=true&site_notic
ET. Attempts will be disabled during this time period. Once the maintenance window concludes, assignments will be available again.

Comprehensive Assessment Results | Turned In

Advanced Health Assessment - Tampa - Winter 2021 , NSG 5502 - 24889
Return to Assignment (/assignments/437039/)

Your Results Lab Pass (/assignment_attempts/9220003/lab_pass.pd

Overview
Documentation / Electronic Health Record
Transcript

Subjective Data Collection Documentation

Objective Data Collection

Vitals
Documentation

Program Competency Progress Student Documentation Model Documentation

Vitals
• Height: 170 cm
Height- 170cm
• Weight: 84 kg
Weight- 90kg
• BMI: 29.0
BMI- 29
• Blood Glucose: 100
BG- 100
• RR: 15
RR- 15
• HR: 78
HR- 78
• BP:128 / 82
BP- 128/82
• Pulse Ox: 99%
O2- 99%
• Temperature: 99.0 F
Temp.- 99.0F

Health History
Student Documentation Model Documentation

Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African American single
woman who presents for a pre-employment physical. She is th
Miss Jones is a 28-year-old AA female who presents for pre-
primary source of the history. Ms. Jones offers information free
employment physical. She is a reliabel historian with clear speech
and without contradiction. Speech is clear and coherent. She
and makes eye contact throughout exam.
maintains eye contact throughout the interview.

General Survey Ms. Jones is alert and oriented, seated upright on the examina
table, and is in no apparent distress. She is well-nourished, we
She is alert and oriented and appears in good health.
developed, and dressed appropriately with good hygiene.

Reason for Visit

“I came in because I'm required to have a recent physical exa
"I came in because I'm required to have a recent physical exam
for the health insurance at my new job.”
for the health insurance at my new job."

Support
This study source was downloaded by 100000845958415 from CourseHero.com on 04-04-2025 01:26:10 GMT -05:00

https://app.shadowhealth.com/assignment_attempts/9220003 1/6
https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/
2/25/2021 Comprehensive Assessment | Completed | Shadow Health

Student Documentation Model Documentation

Ms. Jones reports that she recently obtained employment at

Smith, Stevens, Stewart, Silver & Company. She needs to obta
pre-employment physical prior to initiating employment. Today
History of Present Illness she denies any acute concerns. Her last healthcare visit was 4
months ago, when she received her annual gynecological exa
Denies any acute illness. Reports just needing pre-employment
Shadow Health General Clinic. Ms. Jones states that the
physical. Last exam 4months ago for pap smear. Reports diabetes
gynecologist diagnosed her with polycystic ovarian syndrome
which she is taking Metforming, diet and exercise for treatment.
prescribed oral contraceptives at that visit, which she is tolera
Reports feeling healthy and taking better care of her health with
well. She has type 2 diabetes, which she is controlling with die
increased exercise and imporving diet.
exercise, and metformin, which she just started 5 months ago
She has no medication side effects at this time. She states tha
she feels healthy, is taking better care of herself than in the pa
and is looking forward to beginning the new job.

• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this

Medications morning)
• Metformin, 850 mg PO BID (last use: this morning)
Metformin 850mg PO BID • Drospirenone and ethinyl estradiol PO QD (last use: this
Flovent morning)
Drospierenone/Ethinyl Estradiol • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three
Proventil inhaler PRN months ago)
Advil • Acetaminophen 500-1000 mg PO prn (headaches)
• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken
weeks ago)

• Penicillin: rash
Allergies • Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to allergens s
Reports allergies to cats and penicillin.
states that she has runny nose, itchy and swollen eyes, and
increased asthma symptoms.

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler

when she is around cats. Her last asthma exacerbation was th
months ago, which she resolved with her inhaler. She was last
hospitalized for asthma in high school. Never intubated. Type
diabetes, diagnosed at age 24. She began metformin 5 month
Medical History ago and initially had some gastrointestinal side effects which h
since dissipated. She monitors her blood sugar once daily in t
Asthma diagnosed as a child.
morning with average readings being around 90. She has a his
Diabete type 2, began metformin 5 months ago. Monitors BG
of hypertension which normalized when she initiated diet and
daily.
exercise. No surgeries. OB/GYN: Menarche, age 11. First sexu
HX of HTN.
encounter at age 18, sex with men, identifies as heterosexual.
LMP 2 weeks ago.
Never pregnant. Last menstrual period 2 weeks ago. Diagnose
with PCOS four months ago. For the past four months (after
initiating Yaz) cycles regular (every 4 weeks) with moderate
bleeding lasting 5 days. Has new male relationship, sexual
contact not initiated. She plans to use condoms with sexual
activity. Tested negative for HIV/AIDS and STIs four months ag

Last Pap smear 4 months ago. Last eye exam three months ag
Last dental exam five months ago. PPD (negative) ~2 years ag
Health Maintenance Immunizations: Tetanus booster was received within the past y
influenza is not current, and human papillomavirus has not bee
Last pap smear 4 months ago.
received. She reports that she believes she is up to date on
Last dental exam 5 monhts ago.
childhood vaccines and received the meningococcal vaccine f
Last eye exam 3 months ago.
college. Safety: Has smoke detectors in the home, wears seat
in car, and does not ride a bike. Uses sunscreen. Guns, having
belonged to her dad, are in the home, locked in parent’s room

This study source was downloaded by 100000845958415 from CourseHero.com on 04-04-2025 01:26:10 GMT -05:00

https://app.shadowhealth.com/assignment_attempts/9220003 2/6
https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/
2/25/2021 Comprehensive Assessment | Completed | Shadow Health

Student Documentation Model Documentation

• Mother: age 50, hypertension, elevated cholesterol

• Father: deceased in car accident one year ago at age 58,
hypertension, high cholesterol, and type 2 diabetes
• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma
Family History • Maternal grandmother: died at age 73 of a stroke, history of
hypertension, high cholesterol
Patients mom is 50 years old has HTN and high cholesterol. • Maternal grandfather: died at age 78 of a stroke, history of
Paternal grandmother is only living grand parent. hypertension, high cholesterol
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history
type 2 diabetes
• Paternal uncle: alcoholism
• Negative for mental illness, other cancers, sudden death, kid
disease, sickle cell anemia, thyroid problems

Never married, no children. Lived independently since age 19,

currently lives with mother and sister in a single family home, b
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 History social support system. She states that family and church help
cope with stress. No tobacco. Cannabis use from age 15 to ag
Lives with mom. Attends church. Works full time, just got a new
21. Reports no use of cocaine, methamphetamines, and heroi
job. Graduated college with Bachelors degree. Denies smoking or
Uses alcohol when “out with friends, 2-3 times per month,”
drug use. Reports social alcohol consumption.
reports drinking no more than 3 drinks per episode. Typical
breakfast is frozen fruit smoothie with unsweetened yogurt, lu
is vegetables with brown rice or sandwich on wheat bread or l
fat pita, dinner is roasted vegetables and a protein, snack is ca
sticks or an apple. Denies coffee intake, but does consume 1-
diet sodas per day. No recent foreign travel. No pets. Participa
in mild to moderate exercise four to five times per week consis
of walking, yoga, or swimming.

Reports decreased stress and improved coping abilities have

Mental Health History improved previous sleep difficulties. Denies current feelings of
depression, anxiety, or thoughts of suicide. Alert and oriented
Reports decresed stress. No recent episode of depression or
person, place, and time. Well-groomed, easily engages in
anxiety.
conversation and is cooperative. Mood is pleasant. No tics or
facial fasciculation. Speech is fluent, words are clear.

Review of Systems - General

No recent or frequent illness, fatigue, fevers, chills, or night
No recent illness. Denies fever. Reports weight loss due to diet sweats. States recent 10 pound weight loss due to diet chang
and exercise. and exercise increase.

HEENT
Student Documentation Model Documentation

Reports no current headache and no history of head injury or

acute visual changes. Reports no eye pain, itchy eyes, rednes
dry eyes. Wears corrective lenses. Last visit to optometrist 3
Subjective months ago. Reports no general ear problems, no change in
hearing, ear pain, or discharge. Reports no change in sense of
Denies headache, vision changes, or eye pain. Last eye exam 3
smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhe
months ago.
Reports no general mouth problems, changes in taste, dry mo
pain, sores, issues with gum, tongue, or jaw. No current denta
concerns, last dental visit was 5 months ago. Reports no diffic
swallowing, sore throat, voice changes, or swollen nodes.

This study source was downloaded by 100000845958415 from CourseHero.com on 04-04-2025 01:26:10 GMT -05:00

https://app.shadowhealth.com/assignment_attempts/9220003 3/6
https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/
2/25/2021 Comprehensive Assessment | Completed | Shadow Health

Student Documentation Model Documentation

Head is normocephalic, atraumatic. Bilateral eyes with equal h

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. Mil
retinopathic changes on right. Left fundus with sharp disc
Objective margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left
with corrective lenses. TMs intact and pearly gray bilaterally,
HEENT overall without significant findings.
positive light reflex. Whispered words heard bilaterally. Frontal
Mild reinopathic changes in right eye.
maxillary sinuses nontender to palpation. Nasal mucosa moist
pink, septum midline. Oral mucosa moist without ulcerations o
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
Student Documentation Model Documentation

Subjective
Reports no shortness of breath, wheezing, chest pain, dyspne
Denies wheezing or issues with respiratory system. or cough.

Objective Chest is symmetric with respiration, clear to auscultation

bilaterally without cough or wheeze. Resonant to percussion
WNL throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio
80.56%.

Cardiovascular
Student Documentation Model Documentation

Subjective
Reports no palpitations, tachycardia, easy bruising, or edema
Denies palpitation

Heart rate is regular, S1, S2, without murmurs, gallops, or rubs

Objective Bilateral carotids equal bilaterally without bruit. PMI at the
midclavicular line, 5th intercostal space, no heaves, lifts, or thr
WNL
Bilateral peripheral pulses equal bilaterally, capillary refill less t
3 seconds. No peripheral edema.

Abdominal
Student Documentation Model Documentation

Subjective Gastrointestinal: Reports no nausea, vomiting, pain, constipat

diarrhea, or excessive flatulence. No food intolerances.
Denies issues Genitourinary: Reports no dysuria, nocturia, polyuria, hematur
flank pain, vaginal discharge or itching.

This study source was downloaded by 100000845958415 from CourseHero.com on 04-04-2025 01:26:11 GMT -05:00

https://app.shadowhealth.com/assignment_attempts/9220003 4/6
https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/
2/25/2021 Comprehensive Assessment | Completed | Shadow Health

Student Documentation Model Documentation

Abdomen protuberant, symmetric, no visible masses, scars, o

Objective lesions, coarse hair from pubis to umbilicus. Bowel sounds are
normoactive in all four quadrants. Tympanic throughout to
WNL
percussion. No tenderness or guarding to palpation. No
organomegaly. No CVA tenderness.

Musculoskeletal
Student Documentation Model Documentation

Subjective
Reports no muscle pain, joint pain, muscle weakness, or swel
Denies issues

Objective Strength 5/5 bilateral upper and lower extremities, without

swelling, masses, or deformity and with full range of motion. N
WNL
pain with movement.

Neurological
Student Documentation Model Documentation

Subjective
Reports no dizziness, light-headedness, tingling, loss of
Denies issues. coordination or sensation, seizures, or sense of disequilibrium

Objective Normal graphesthesia, stereognosis, and rapid alternating

movements bilaterally. Tests of cerebellar function normal. DTR
Decreased sensation to monofilament bilaterally to bottom of the
2+ and equal bilaterally in upper and lower extremities. Decrea
feet
sensation to monofilament in bilateral plantar surfaces.

Skin, Hair & Nails

Student Documentation Model Documentation

Subjective Reports improved acne due to oral contraceptives. Skin on ne

has stopped darkening and facial and body hair has improved
Denies issues
She reports a few moles but no other hair or nail changes.

Objective
Scattered pustules on face and facial hair on upper lip, acanth
Mild acne to face. Noticed facial hair on upper lip. Darkened skin
nigricans on posterior neck. Nails free of ridges or abnormaliti
to neck. Nails WNL

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

This study source was downloaded by 100000845958415 from CourseHero.com on 04-04-2025 01:26:11 GMT -05:00

https://app.shadowhealth.com/assignment_attempts/9220003 5/6
https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/
 2/25/2021 Comprehensive Assessment | Completed | Shadow Health
© Shadow Health® 2012 - 2021
(800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents
(https://www.shadowhealth.com/patents)

This study source was downloaded by 100000845958415 from CourseHero.com on 04-04-2025 01:26:11 GMT -05:00

https://app.shadowhealth.com/assignment_attempts/9220003 6/6
https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/
Powered by TCPDF (www.tcpdf.org)