COMPREHENSIVE HISTORY AND PHYSICAL EXAM WRITE UP

COMPREHENSIVE HISTORY AND PHYSICAL EXAM WRITE UP

PART 2

Robin Beam, RN NURSE 360 Health Assessment University of Maryland University College Fall 2016 Dr. An’Nita Hebron This study source was downloaded by 100000829725281 from CourseHero.com on 12-20-2021 15:19:13 GMT -06:00 https://www.coursehero.com/file/21649701/COMPREHENSIVE-HISTORY-AND-PHYSICAL-EXAM-WRITE-UP-1/ 1 / 2

Comprehensive History & Physical Exam Write Up, Pt. 2 Health History Ms. Tina Jones is a 28-year old African American woman who presents for a pre- employment physical. She is the primary source of history. She is alert and oriented to self, time, place and situation. Her mood is pleasant. Her language is fluent and speech is clear. She maintains eye contact throughout the interview. She is seated in an upright position on the examination table. She is neatly dressed, has good hygiene and appears well-nourished. She is not in any distress.Ms. Jones states that her last health exam was four months ago, when she received a gynecological exam. She was diagnosed with polycystic ovarian syndrome and prescribed oral contraceptives at that visit. She takes Yaz oral contraceptives by mouth once a day and is tolerating it well. She reports that her menstrual cycles are regular with moderate bleeding lasting five days since taking Yaz. During her gynecological visit, she had a pap smear and tested negative for STI’s and HIV. She states that she is involved in a new heterogeneous relationship and plans to use condoms with sexual activity.Ms. Jones has type 2 diabetes. She controls her diabetes with diet, exercise and Metformin 850 mg by mouth twice a day, which she started taking again five months ago. She monitors her blood glucose once every morning. She controls her hypertension with diet and exercise as well.At the age of 2.5 years, Ms. Jones was diagnosed with asthma. Her last hospitalization due to asthma was while she was in high school. She has never been intubated. She managers her asthma with Albuterol 90 mcg/spray MDI 2 puffs every four hours as needed and Fluticasone propionate 110 mcg 2 puffs twice a day. Her last asthma exacerbation was three months ago.Ms. Jones takes Ibuprofen 600 mg by mouth as needed for menstrual cramps. She also takes Acetaminophen as needed for headaches.

• This study source was downloaded by 100000829725281 from CourseHero.com on 12-20-2021 15:19:13 GMT -06:00

https://www.coursehero.com/file/21649701/COMPREHENSIVE-HISTORY-AND-PHYSICAL-EXAM-WRITE-UP-1/

• / 2