Tina jones Shadow Health Comprehensive exam Essay.
Follow the instructions to the case, but instead of creating the H&P note in the EHR, the student will create an H&P note to submit in Blackboard. You are to use Shadow Health\’s DCE, \”Comprehensive Assessment of Tina Jones\” Compose each component of the H&P based on the information/interaction with Tina Jones Identify >3 diagnosis (dx)- primary (the main reason she presents with) and additional dx-existing chronic problems, prioritized. Write a basic plan of care/treatment based on the diagnosis. In the treatment, write 2 medication prescriptions (may include OTC products) excluding title page)Follow APA format for document and create a title page.Tina jones Shadow Health Comprehensive exam Essay.
CC: “Today I do not have any health concerns. I only came for a preemployment physical assessment that is needed by the insurance organization”
Medical Hx:Ms. Jones presented to the Shadow Health Clinic for a comprehensive physical assessment required at her place of work where she recently secured employment. Ms. Jones does not have any current health concerns. She reported that 16 weeks ago shed visited the clinic for the yearly for gynecological assessment where she was diagnosed with PCOS. The gynecologist prescribed oral contraceptives for PCOS. She reported that the contraceptives have been so helpful in stabilizing her menstrual periods and now she gets her menses every month.Tina jones Shadow Health Comprehensive exam Essay. The patient reported that she was diagnosed with asthma during childhood but it is well controlled. She further reported that at the age of 24 years she had type 2 diabetes diagnosis. Four months ago, she started using metformin to manage diabetes. She also engages in exercises and physical activities to control and manage diabetes. The patient denied any form of stress, anxiety, depression, sleep disturbances, or any other mental problem. She reported that these days she feels healthier, has made positive lifestyle modifications, and she is excited and looking forward to starting her new job.Tina jones Shadow Health Comprehensive exam Essay.
Social: In a relationship; no children; not married; lives with her mother but considering moving out soon; goes swimming with her friend; takes alcohol occasionally; does not smoke or use drugs; an active member in the church and attend Bible study
Family: Father: died at the age of 58 years; had diabetes; high blood pressure; high cholesterol
Mother: Has high blood pressure and high levels of cholesterol
Sister: Has asthma
Maternal grandmother: She died from a stroke and had both high blood pressure and high levels of cholesterol
Maternal grandfather: died from a stroke and had both high blood pressure and high levels of cholesterol
Paternal grandfather: Had type 2 diabetes and succumbed to colon cancer
Medications: Metformin for diabetes; Flovent and Albuterol for asthma
Allergies: Allergicto penicillin, cats, and dust
Review of Systems
General: Ms. Jones seems to be in good health and she does not have any acute illness. She reports that she has lost weight recently due to her current lifestyle modifications.Tina jones Shadow Health Comprehensive exam Essay.
HEENT: She denied any visual problems; no headache; no nasal problems; denies any dental problems or sore throat or any swallowing difficulties
Skin: She reports that the acne has significantly improved; both body and facial hair has improved; the skin on the neck has also improved
Respiratory: No chest pain; denies any breathing problems; denies coughing or dyspnea; no wheezing
Cardiovascular: No high heartbeat or palpitations
Gastrointestinal: Denies any constipation; abdominal pain, vomiting, diarrhea or food intolerance
Urinary: No vaginal itching or abnormal discharge; denies any pain; blood in the urine; excess urination at night or excessive urination
Diet: Has adopted a healthy diet that mainly consists of vegetables, fruits and small amounts of proteins and carbohydrates
Endocrine: Does not report any heat/cold; denies any excessive thirst
Musculoskeletal: Denies any muscle weakness or pain; denies joint pain
Neurological: Denies dizziness; numbness, lightheadedness or tingling; Does not report any loss of sensation, coordination problems or loss of balance
Psychiatric: Denies any form of anxiety, sleep problems or depression
Vital signs: Pulse rate 78; Respiratory 15; Blood pressure 128/82 mm Hg;Temperature 37. 2 c; Height 170 cm; Weight 84 kgs; and BMI 29
HEENT: The head is normocephalic; nasal mucosa and oral mucosa moist; intact gag reflex;Thyroid smooth; no goiter; Tonsils 2+ bilaterally
Skin: Visible acne on the face; No abnormalities in nails; Normal scalp; hairy face
Respiratory: Lung sound clear and present in all areas; both posterior and anterior chest normal; chest clear to auscultation; symmetric chest with respiration and expansion; SpirometryFEV1/FVC ratio 80.56%; FVC 3.91 L
Cardiovascular: No murmurs in the heart; regularheart rate; norubs or gallopsin S1, S2; capillary refill > 3 seconds; 5th intercostal space; No peripheral edema; No heaves at the intercostal space; PMI at the midclavicular
Gastrointestinal: Symmetric abdomen; Bowel sounds present and normal; No abnormalities or masses in the abdomen; Tympanic quadrants; No CVA tenderness
Musculoskeletal: Full range of motion (FRM) present within all joints; No joint pain with movement; no deformity or swelling
Neurological: Normal cerebellar function; Normal rapid alternating movements bilaterally
Psychiatric: No anxiety, sleep disturbances, depressive thoughts or nervousness
N/A because Ms. Jones denied any acute illness or health concern during her visit because she presented fora pre-employment physical exam needed at her new workplace).Tina jones Shadow Health Comprehensive exam Essay.
Patient Education: Ms. Jones has type 2 diabetes and thus she need education regarding the significance of closely monitoring her blood glucose levels to avoid any complications. She will also be educated on the importance of making positive lifestyle modifications and adhering to the prescribed treatment regimen for both diabetes and asthma conditions.Tina jones Shadow Health Comprehensive exam Essay.
Preventive care: The patient will be educated to avoid any allergens and make sure that all vaccinations are up-to-date
Follow-up instructions: N/A because Ms. Jones did not report any acute during the visit
The NONPF competencies that were addressed during Ms. Jones’ visit include technology and information literacy competencies;independent practice competencies; and Practice inquiry competencies. Therefore, during the visit, I used research evidence and my clinical experience to inform Ms. Jones about the required lifestyle modifications like adopting a healthy and nutritious diet and being physically active (Heinen et al., 2019).Tina jones Shadow Health Comprehensive exam Essay. Ms. Jones was also educated to avoid allergens and closely monitor her blood glucose levels to avoid any complications. Therefore, evidence was utilized to inform practice in order to improve the health outcomes of Ms. Jones. As required for NPs, I assessed Ms. Jones independently and recommended the appropriate measures for Ms. Jones. Finally, I applied information technology by documenting Ms. Jones’ health information in electronic health records (EHR) to manage her information (Christiansen & Champion, 2018).Tina jones Shadow Health Comprehensive exam Essay.
Christiansen, B., & Champion, J. D. (2018). Examining doctor of nursing practice clinical competency. The Journal for Nurse Practitioners, 14(5), e93-e100.
Heinen, M., van Oostveen, C., Peters, J., Vermeulen, H., & Huis, A. (2019). An integrative review of leadership competencies and attributes in advanced nursing practice. Journal of advanced nursing, 75(11), 2378-2392.
Jaroudi, S., & Payne, J. D. (2019). Remembering Lawrence Weed: a pioneer of the SOAP note. Academic Medicine, 94(1), 11.
Tina jones Shadow Health Comprehensive exam Essay.