Shadow Health Comp Assessment.
Latest 2022. Graded A+
Identifying Data & Reliability - Ans--Ms. Jones
-28-year-old
-African American
-single
-religious preference
-Education
-Occupation: Smith, Stevens, Stewart,
...
Shadow Health Comp Assessment.
Latest 2022. Graded A+
Identifying Data & Reliability - Ans--Ms. Jones
-28-year-old
-African American
-single
-religious preference
-Education
-Occupation: Smith, Stevens, Stewart, Silver & Company
-Occupational history
-woman
-presents for a pre- employment physical. -She is the primary source of the history. -offers information
freely and without contradiction.
-Mrs. Jones Reliable historian
General Survey - Ans-Alert/oriented
-seated upright
-well-nourished
-well-developed
-dressed appropriately
-good hygiene.
Reason for Visit - Ans-SEE HPI
history of present illness - Ans-HPI: "pre-employment physical" prior to initiating employment."
Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the
past"Medications - Ans-+ Fluticasone propionate 110 mcg 2 puffs BID, Metformin, 850 mg PO BID,
Drospirenone, ethinyl estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen
500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps)
-using topical antifungals, anti-itch creams, steroid topical ointments, eye/ear/sublingual drops,
Benadryl, herbs gingko/garlic/primrose.
Allergies - Ans-+Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes)
-Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies.
Health Maintenance - Ans-+ Pap smear (4 months ago), eye exam (three months ago), dental exam (five
months ago), PPD (negative, about 2 years ago), wears seatbelt, uses sunscreen.
-Acupuncture, chiropractic care, changes in behavior/personality/mood, memory problems, difficulty
learning.
Medical History - Ans-+ Asthma (diagnosed 24 years old), hypertension (resolved with diet/exercise),
PCOS (Diagnosed 4 months ago), received childhood vaccinations, meningococcal vaccine (in college),
hospitalized in high school for asthma exacerbations (resolved with use of inhaler without complication),
tetanus booster (within last year),
-Childhood chickenpox/rubella/polio, serious injuries MVA/broken bones/spinal cord injury, using a
walker/cane/hearing aids, appendectomy, tonsillectomy, wisdom teeth removal, transfusion of
blood/platelets/red blood cells, current flu vaccine.
Family History - Ans-• Father: deceased in car accident one year ago at age 58, hypertension, high
cholesterol, and type 2 diabetes• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma• Maternal grandmother: died at age 73 of a stroke, history of
hypertension, high cholesterol• Maternal grandfather: died at age 78 of a stroke, history of
hypertension, high cholesterol• Paternal grandmother: still living, age 82, hypertension• Paternal
grandfather: died at age 65 of colon cancer, history of type 2 diabetes• Paternal uncle: alcoholism•Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid
problems
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