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NR 509 Tina jones foot overview

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Tina Jones is a 28 year old African american female AOX4. Pt is reliable historian 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 the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Alert and oriented X4. Feels tired because she was just coming from her other job. 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. Health Promotion Involving Tina Jones Reason for Visit Presenting to shadow health hospital clinic for a complete health assessment for a pre-employment physical. “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 Tina Jones is a 28year old African America female with a history of diabetes and Asthma presenting to get a complete health assessment for a pre-employment physical. 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. [Show More]

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