Health promotion | Nursing homework help
Identifying Data & Reliability
Tina Jones is a 28 year old African american womanly AOX4. Pt is veritable historian
Ms. Jones is a desirable, 28-year-old African American unmarried woman who presents for a pre-possession corporeal. She is the primitive commencement of the narrative. Ms. Jones offers notification gratuitously and outedge confliction. Speech is disencumbered and sensible. She maintains eye continuity throughout the consultation.
Alert and oriented X4. Feels wearied accordingly she was orderly future from her other job.
Ms. Jones is ready and oriented, seated fair on the evidence table, and is in no presumable harass. She is polite-nourished, polite-developed, and expert properly succeeding a while amiable hygiene.
Reason for Visit
Presenting to attendant vigor hospital clinic for a total vigor toll for a pre-possession corporeal.
"I came in accordingly I'm required to enjoy a fresh corporeal exam for the vigor protection at my new job."
History of Present Illness
Tina Jones is a 28year old African America womanly succeeding a while a narrative of diabetes and Asthma presenting to get a total vigor toll for a pre-possession corporeal.
Ms. Jones reports that she freshly conquered possession at Smith, Stevens, Stewart, Silver & Company. She needs to conquer a pre-possession corporeal former to initiating possession. Today she denies any intelligent concerns. Her conclusive vigorattention mark was 4 months ago, when she ordinary her annual gynecological exam at Attendant Vigor General Clinic. Ms. Jones states that the gynecologist diagnosed her succeeding a while polycystic ovarian syndrome and prescribed traditional contraceptives at that mark, which she is tolerating polite. She has symbol 2 diabetes, which she is powerful succeeding a while foundation, training, and metformin, which she orderly instituted 5 months ago. She has no medication edge possessions at this span. She states that she feels vigory, is induction amend attention of herself than in the spent, and is looking self-assertive to opening the new job.
Metformin 850mg twice daily Yaz lineage curb daily in the waking Flovent MDI twice daily proventil 90mcg/spray 2 puffs as needed for wheezing
• Fluticasone propionate, 110 mcg 2 puffs BID (conclusive use: this waking) • Metformin, 850 mg PO BID (conclusive use: this waking) • Drospirenone and ethinyl estradiol PO QD (conclusive use: this waking) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (conclusive use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: conclusive enthralled 6 weeks ago)
Penicillin- Rash, hives cats- sneezing, itchy oft eyes, asthma exacebation No Known foundation allergies No latex allergies
• Penicillin: headpungent-muscular • Denies foundation and latex allergies • Allergic to cats and carcass. When she is defenseless to allergens she states that she has runny nose, itchy and rising-flown eyes, and increased asthma symptoms.
Asthma- diagnosed at age 2 1/2 Diabetes Symbol 2 - diagnosed at 24 was on metformin but stopped due to edge possessions
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is encircling cats. Her conclusive asthma exacerbation was three months ago, which she grounded succeeding a while her inhaler. She was conclusive hospitalized for asthma in rising nurture. Never intubated. Symbol 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal edge possessions which enjoy gone rapid. She monitors her respect sugar unintermittently daily in the waking succeeding a while mean lections substance encircling 90. She has a narrative of hypertension which normalized when she prepared foundation and training. No surgeries. OB/GYN: Menarche, age 11. First sexual attack at age 18, sex succeeding a while men, identifies as heterosexual. Never outgrowthful. Conclusive menstrual end 2 weeks ago. Diagnosed succeeding a while PCOS lewd months ago. For the spent lewd months (succeeding initiating Yaz) cycles orderly (integral 4 weeks) succeeding a while sparing bleeding conclusiveing 5 days. Has new manful connection, sexual continuity not prepared. She plans to use condoms succeeding a while sexual vital-force. Tested disclaiming for HIV/AIDS and STIs lewd months ago.
Has been eating vigory and enigmatical to cling locomotive by walking 30-40 mins two spans per week and also swimming unintermittently a week
Last Pap daub 4 months ago. Conclusive eye exam three months ago. Conclusive dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was ordinary succeeding a whilein the spent year, influenza is not popular, and anthropological papillomavirus has not been ordinary. She reports that she believes she is up to end on childhood vaccines and ordinary the meningococcal vaccine for propaganda. Safety: Has steam detectors in the settlement, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the settlement, locked in parent’s admission.
-Father died 2 1/2 ears ago in a car surroundings. Narrative of rising respect urgency,symbol 2 diabetes and rising cholesterol -Mother is stagnant subsisting. has narrative of hypertension and rising cholesterol. -Brother is overweight -Sister has asthma
• Mother: age 50, hypertension, rising cholesterol • Father: peaceful in car surroundings one year ago at age 58, hypertension, rising cholesterol, and symbol 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a pat, narrative of hypertension, rising cholesterol • Maternal grandfather: died at age 78 of a pat, narrative of hypertension, rising cholesterol • Paternal grandmother: stagnant livelihood, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, narrative of symbol 2 diabetes • Paternal uncle: alcoholism • Disclaiming for intangible sickness, other cancers, quick exit, lineage disorder, sickle cell anemia, thyroid problems
she does not enjoy any conclusion, has never been outgrowthful and has never been married. she lives succeeding a while her woman and sister. popularly works but is hoping to set-on-foot a new jop as an accounting clerk at smith, stevens, steward silver congregation. drinksa alcohol ocassionally when she goes out succeeding a while friends
Never married, no conclusion. Lived independently gone age 19, popularly lives succeeding a while woman and sister in a unmarried lineage settlement, but accomplish instigate into own berth in one month. Accomplish arise her new standing in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending span succeeding a while friends, lection, attending Bible consider, volunteering in her pavilion, and dancing. Tina is locomotive in her pavilion and describes a pungent-muscular lineage and gregarious livelihood scheme. She states that lineage and pavilion acceleration her struggle succeeding a while strain. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out succeeding a while friends, 2-3 spans per month,” reports drinking no over than 3 drinks per incident. Typical breakfast is frozen outgrowth smoothie succeeding a while unsweetened yogurt, lunch is vegetables succeeding a while brown rice or sandwich on wheat repast or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does ravage 1-2 foundation sodas per day. No fresh strange tramp. No pets. Participates in meek to sparing training lewd to five spans per week consisting of walking, yoga, or swimming.
Mental Vigor History
Denies any narrative of valley or suicidal thoughts. denies any problems succeeding a while vein. no overall protection concerns.
Reports decreased strain and improved coping abilities enjoy improved prior repose difficulties. Denies popular feelings of valley, care, or thoughts of suicide. Ready and oriented to individual, attribute, and span. Well-groomed, amply engages in talk and is cooperative. Vein is desirable. No tics or facial fasciculation. Speech is fluent, language are disencumbered