NR 509 Tina Jones Shadow Health Comprehensive Assessment

Tina Jones Shadow Health Comprehensive Assessment

NR 509 Tina Jones Shadow Health Comprehensive Assessment

Within the Shadow Health platform, complete the Comprehensive Assessment. The estimated average time to complete this assignment each time is 3 hours. Please note, that this is an average time. Some students may need longer.

This clinical experience is a comprehensive exam. Students must score at the level of “Proficiency” in the Shadow Health Digital Clinical Experience. Students have three opportunities to complete this assignment and score at the Proficiency level. Upon completion, submit the lab pass through the Shadow Health assignment dropbox.

Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 150 points; students successfully scoring at the Proficiency level on the second attempt will earn a grade of 135 points, and students successfully scoring at the Proficiency Level on the third attempt will earn a grade of 120 points. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (102 points).

If Proficiency is not achieved on the first attempt it is recommended that you review your answers with the correct answers on the Experience Overview page. Review the report by clicking on each tab to the left titled; Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. Reviewing this overview and course resources may help you improve your score.

Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to LopesWrite. Tina Jones Shadow Health Comprehensive Assessment

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Vitals
Student Documentation Model Documentation
Vitals

Ms. Jones is 170 cm tall and weighs 89 kgs, which makes her BMI 30.8
Her random blood glucose level is 199.
Her present temperature is 99.1 degress Fahreinheit.

BP: 141/82
HR: 80
RR: 16
02: 99%

• Height: 170 cm
• Weight: 84 kg
• BMI: 29.0
• Blood Glucose: 100
• RR: 15
• HR: 78
• BP:128 / 82
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability

Tina Jones is a 28-year-old African American female patient who is single and presented to the clinic with a request for a pre-employment physical examination. She acts as the primary source of the data offered for the assessment. She offers information freely without contradicting herself. Her speech is clear and coherent. She maintains eye contact throughout the whole interview.

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 history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
General Survey

Ms. Tina Jones is oriented as well as alert, seated in an upright position, and doe not show any apparent sign of distress. She is well-developed, well-nourished, and dressed appropriately with excellent 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. Tina Jones Shadow Health Comprehensive Assessment
Reason for Visit

“i came in because I am 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

Ms. Tina Jones reports that she was recently hired by Smith, Stevens, Stewart, Silver, and Company. She requires to acquire 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 Clinic. Ms. Tina Jones states that the gynecologist diagnosed her with the polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is well tolerating. She has type II diabetes, which she controls using diet, exercise, and metformin that she had just begun five months prior. SWhe has no medication side effects at this point. She reports that she feels healthy, is taking great care of herself compared to the past, and is looking forward to starting her job.

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

Fluticasone Propionate, 110 mcg, 2 puffs BID whose last use was this morning; Drospirenone and Ethinyl estradiol PO QD last use was this morning; Albuterol 90 mcg/spray MDI 2 puffs, Q4H prn last use was three months ago; Acetaminophen 500-1000 mg PO PRN for headaches; Ibuprofen 600 mg PO TID PRN for menstrual cramps and last use was six weeks ago, Tina Jones Shadow Health Comprehensive Assessment

• 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

Penicillins causes rash; Denies food and latex allergy; Allergic to cats and dust. Ms. Jones reports that allergens cause runny nose, itchy and swollen eyes, and enhanced asthma symptoms.

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

Ms. Jones reports that her asthma was diagnosed at the age of 21/2 years. She reports using her Albuterol inhaler when around cats. Her last asthma exacerbation occurred three months ago and she reports resolving it using the inhaler. She was last hospitalized for asthma attacks in high school. Never intubated. Type 2 diabetes whose diagnosis occurred at the age of 24. She reports beginning metformin 5 months ago and initially had some GI adverse effects that have since diminished. She reports monitoring her blood once daily in the morning with average readings being around 90. She has a history of hypertension that normalized when she initiated exercise and diet. Denies surgeries.

OB/GYN: Reports menacrche at age 11. Reports having first sexual encounter at 18 years, having sex with men, and identifies as heterosexual. Denies ever being pregnant. Reports last menstrual period was 2 weeks ago. Reports being diagnosed with PCOs four months ago. For the past 4 months, after initiating Yaz, she reports that her cycles have become regular with moderate bleeding the last 5 days. Reports having a new male relationship denies initiating sexual contact. She reports planning to use condoms for sexual activity. They tested negative for HIV/AIDS and STIs four months ago.

Asthma was diagnosed at age 2 1/2. She uses her albuterol inhaler when she experiences exacerbations, such as around dust or cats. Her last asthma exacerbation was yesterday, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90.

She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identify as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles were regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms for sexual activity. They tested negative for HIV/AIDS and STIs four months ago.
Health Maintenance

Reports that the last pap smear was four months ago. Reports last eye exam was three months ago. PPD was negative two years ago.
Immunizations: A tetanus booster was received within the past year; influenza is not current. The patient has not received human papillomavirus. Reports that Rep’s childhood vaccines are up to date. Reports receiving the meningococcal vaccine for college.
Safety: Reports having smoke detectors at home, wears seat belts in the car, and denies riding a car. Reports using sunscreen. Reports having guns belonging to her dad that is locked in the bedroom.

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

Mother: 50 years of age, has hypertension and elevated cholesterol.
Father: Deceased in a car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes.
Brother: Called Michael, is 25 years of age, and overweight.
Sister: Called Brittany, is 14 years, asthmatic.

Maternal grandmother: Died of a stroke aged 73 years, has a history of hypertension, and high cholesterol.
Maternal grandfather: Died aged 78, stroke, history of hypertension, high cholesterol.
Paternal grandmother: Died aged 65 years of colon cancer, history of type 2 diabetes. Tina Jones Shadow Health Comprehensive Assessment
Paternal uncle: alcoholism
Negative for mental illness, other cancers, sudden death, kidney disease, thyroid problems, and sickle cell anemia.

• Mother: age 50, hypertension, elevated cholesterol
• Father: deceased in a car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes
• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma
• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
• Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems
Social History

Ms. Jones reports never being married. She denies having children. Reports living independently for 19 years. Reports currently living with mother and sister in a single-family home. She reports that she will move to her own apartment in a month. She reports that she will start her new position at Smith, Stevens, Silver, and Company in two weeks.

Reports that she enjoys spending time with friends, attending Bible study, volunteering in church, reading, and dancing. She states that family and church help her cope with stress. Denies tobacco. Reports using cannabis from age 15-21. Denies use of cocaine, heroin, and methamphetamine. Reports using alcohol when out with friends 2-3 times per month. Reports drinking more than three drinks per sitting. Typical breakfast is a frozen fruit smoothie, with unsweetened yogurt, lunch is vegetables with brown rice or a sandwich on wheat bread or low-fat pita. Dinner is roasted vegetables and protein. The snack is carrot sticks or an apple. Denies coffee intake but does consume 1 or 2 diet sodas per day. Denies pets. Reports participating in mild to moderate exercise 4 to 5 times per week comprising walking, swimming, and yoga.

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 a frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or a 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

Reports decreased stress and enhanced coping strategies. Reports improved sleep difficulties. Denies current feelings of depression, anxiety, and suicidal thoughts. Alert and oriented to persons, place, and time. Well-groomed, easily engages in conversation, and is cooperative. Mood is plessant with no tics or facial fasciculation. Speech is fluent, and words are clear.

Reports of 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. The mood is pleasant. No tics or facial fasciculation. Speech is fluent, and words are clear.
Review of Systems – General

No recent or frequent illness, fatigue, fevers, night sweats, or chills. States recent 10-pound loss due to toi diet change and exercise increase.

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
Student Documentation Model Documentation
Subjective

“I am doing well”. Reports no current headache and no history of head injury or acute visual changes. Denies eye pain. itchy eyes, redness, or dry eyes. Wears corrective lenses. The last visit to the optometrist was three 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 pressure or pain, or rhinorrhea. Denies general mouth problems, changes in taste, dry mouth, pain, sores, jaw, tongue, or issues with gum. Denies difficulty in swallowing, swollen nodes, voice changes or sore throat.

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, or issues with gum, tongue, or jaw. No current dental concerns, the last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.
Objective

The Head is normocephalic and atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids with our lesions, no ptosis, or edema. Conjunctive pink, no lesions, white sclera. PERRLA bilaterally. EOMS is intact bilaterally, with 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 with pearly gray bilaterally, positive light reflex. Whispered words are heard bilaterally. Frontal and maxillary sinuses non-tender 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.

The Head is normocephalic, and 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 are 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
Student Documentation Model Documentation
Subjective

Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.

Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.
Objective

Chest is symmetric with registration, clear to auscultation bilaterally minus cough or wheeze. Resonant to percussion throughout. In-office spirometry: FVC 3.91 L, FEV 1/ FVC ratio 80.56%.

Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion 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.

Reports no palpitations, tachycardia, easy bruising, or edema.
Objective

Heart rate is regular, S1, S2, minus murmurs, gallops, or rubs. Bilateral carotids equal bilaterally minus bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves or lifts. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.
Abdominal
Student Documentation Model Documentation
Subjective

Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances.

Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge, or itching.

Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching. Tina Jones Shadow Health Comprehensive Assessment
Objective

Abdomen protuberant, no visible masses, scars or lessons, coarse hair from the pubis to the umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from the pubis to the umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to 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 swelling.

Reports no muscle pain, joint pain, muscle weakness, or swelling.
Objective

Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with a full range of motion. No pain with movement.

Bilateral upper and lower extremities without swelling, masses, or deformity and with the full range of motion. No pain with movement.
Neurological
Student Documentation Model Documentation
Subjective

Denies dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.

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

Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in lower and upper extremities. Decreased sensation in 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
Student Documentation Model Documentation
Subjective

Reports improved acne due to oral contraceptives. The skin on the neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.

Reports improved acne due to oral contraceptives. The skin on the neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.
Objective

Scattered pustules on the face and facial hair on upper lips, acanthosis nigricans on the posterior neck. Nails free of ridges or abnormalities.

Scattered pustules on the face and facial hair on the upper lip, acanthosis nigricans on the posterior neck. Shadow Health Assessment Help 

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