Tina Jones Comprehensive Assessment. Tina Jones is a 28 year old African America Woman with hypertension (HTN), high cholesterol, diabetes, and colon cancer.

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Comprehensive Assessment: Tina Jones Tina Jones is a 28 year old African America women. She came into the clinic for a physical exam. She is starting a new job as an accounting clerk at Smith, Ste... wart, Silver & Company. She is required to have a physical exam for her health insurance. Tina's health history was taken, a physical assessment was done and a plan of care was made. Health History Health history is a very important part of assessment for practitioners. When interviewing the patient the practitioner is able to get a health history and the history of the patients chief complaint. Through the interview process the practitioner is als o able to find out what the patient believes is most important about their health (Bickley, 2013). Tina is a 28 year old African American women. She is in the clinic today for a physical exam for her new job. She is the primary source of health history. Tina's speech is clear and coherent. She maintains eye contact throughout the interview. Tina is alert and oriented. She is well-developed and dress appropriately with good hygiene. She does not appear to be in any distress. Tina is allergic to cats, she states that she tries to avoid cats but when she is around them her asthma "acts up" (T. Jones, Shadow Health Interview, February 13, 2016). She states that she has tightness in her chest and wheezing. She is allergic to PCN. She states that she "got a ra sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). She denies any food and latex allergies. She denies having any recent allergies to dust or pol len. She states that she has had problems in the past but they have not h appened in "a while" (T. Jones, Shadow Health Interview, February 13, 2016). She states that her daily inhaler has helped with her environmental allergies. Tina has been diagnosed with diabetes, asthma and polycystic ovarian syndrome (PCOS). Tina was diagnosed with Diabetes at age 24. Tina checks her blood sugar once a day, in the morning. Her diabetes is being treated with metformin 850 mg PO BID. She has changed her diet recently to help with her diabetes. She limits her carbohydrates and avoids sugar. Tina was diagnosed with asthma at age 2 1/2. She is treating her asthma with a daily inhaler as well as a rescue inhaler. Her daily inhaler is Flovent 88mcg/spray MDI 2 puff BID. Her rescue inhaler is 90 mcg/spray MDI 2 puff PRN for shortness of breath. She states that her daily inhaler has improved her asthma. She states that her last asthma attack was 3 months ago. She states that when she has an attack her chest feel tight and she has wheezing. She states that it feels like she "cant' get enough air”. Her last asthma related hospitalization was when she was 16. She states that her asthma is worst when around cats but she also has problems with dust and running up stairs. Tina was recently diagnosed with PCOS . Her OB/GYN started her on Yaz birth control to treat the PCOS. The Yaz is being used to co ntrol and lessen symptoms of PCOS. She has noticed that her periods are more regular and her cramps are not "as bad " (T. Jones, Shadow Health Interview, February 13, 2016). She also states that her menstrual flow is medium. She had a pap smear done 4 months ago. She uses Advil to treat her cramps when she gets them (T. Jones, Shadow Health Interview, February 13, 2016). TINA JONES ASSESSMENT - 4 - She has a family history of hypertension (HTN), high cholesterol, diabetes, and colon cancer. Her mother is still aliv e and has high cholesterol and HTN. Her father died a year ago in a car accident. He had a history of HTN, high cholesterol and diabetes. Tina's paternal Grandfather died from Colon cancer and also had HTN and diabetes. Her paternal Grandmother is living and has a history of HTN. Her maternal Grandfather died from a heart attack and had a history of HTN and high cholesterol. Tina's maternal Grandmother died from a stroke and had a history of HTN and high cholesterol. Her Sister has asthma and her Brother i s over - weight (T. Jones, Shadow Health Interview, February 13, 2016) . A review of systems was done with Tina. The practitioner found the following: General: Tina has lost some weight due to diet and exercise changes. Pt denies any fever or night sweats. P t is alert and oriented She is coherent to answer questions. HEENT: Denies fever. Reports that she has not been sick recently. She states that she has been sleeping well and has a good amount of energy. Tina denies any ear problems. She denies any hearing problems or pain in her ears. She is wearing eye glasses. She denies any recent blurry vision. She had an eye appointment 3 months ago. She states that at her eye appointment the doctor stated that she was near sighted and needed to wear glasses. She denie s recent headaches. She states that she has not had a hea da che in 6 months. She thinks that her last headache was when she was studying. Denies any nasal problems or surgeries. She states that she only sneezes when she is around cats. She denies having any nosebleeds. Denies any mouth problems. Denies any changes in taste. Denies mouth pain or dryness. Denies any problems with jaw. Denies any oral surgeries. She states that she went to the dentist 5 months ago. She states that the dentist said her teeth loo ked good. TINA JONES ASSESSMENT - 5 - Denies neck pain. Denies any changes in voice. Respiratory: She denies any shortness of breath, wheezing, cough and chest pain. Cardiac: Tina denies any cardiac problems. She has had elevated BP in the pa st but her BP today is normal. She denies any dizziness or lighthead ed ness. She had an EKG done in the clinic, but she doesn't remember the rests. She states that she know that everything was "normal." She denies any edema and easy bleeding. Abdominal: Tina has lost some wait since her first visit to the Shadow Health Clinic. She has started eating better and exercising. She denies any nausea, diarrhea, constipation or any other GI problems. She states that her bowel movements are regular although she cannot describe her bowel movements. She has no history of GI problems and she has no family history of GI problems. Musculoskeletal: Tina denies any problems with her joints or muscles. She has n o t had any trouble walking and her gait is normal. She denies any pain in her joints at this time. Pt denie s any numbness. She denies any sprains or broken bones. Neurological: Tina is alert and oriented. She is able to hold conversation. No speech issues noted. Pt denies neck pain. She denies any vision changes. She denies any loss of sensation, numbness or ti ngling. Pt denies trouble sleeping (T. Jones, Shadow Health Interview, February 13, 2016) . Tina graduated with her BA in accounting a few months ago. She is starting a new job in two weeks as an accounting clerk. She is currently living with her mom and s ister, but she has plans to move into an apartment next month. She also states that she is in a new relationship. She has been see [Show More]

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