TINA JONES FINAL COMPREHENSIVE ASSESMENT_2020 | NURS 6512 Final Comprehensive assessment_ A Grade

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NURS 6512 FINAL TINA JONES Name: Tina Jones Comprehensive Assessment Vitals: BP- 128/82, HR- 78, RR- 15, TEMP- 37.2C, O2- 99% on room air, HEIGHT- 170CM, WEIGHT- 84KG, BMI- 29, BLOOD SUGAR... - 100, SPIROMETRY- FVC 1.78L, FEV1- 1.549L. Health History Student Documentation Identifying Data & Reliability Ms. Tina Jones is a 28 years old African American female who came into the clinic for pre-employment assessment. she came in alone, alert, and oriented X4, speech is clear and appropriate for her age makes eye contact. Patient dressed appropriately for the weather. Ms. Jones tolerated the assessment with ease. General Survey Patient is oriented to time, place, and situation. Patient is obese but practicing healthy eating and physical activity in her daily routine. Patient appears not to be in distress. She is excited to start her new jo in the city. Reason for visit Patient verbalized “I came in here because, I’m required to have a recent physical examination for the health insurance at my new job.” History of Present illness The patient is here, for physical assessment for work insurance for a new job. Patient presents with other health issues that is under control. She wears a prescription glasses to help with blurry vision and headaches. Medications Metformin 850 mg- started 5 months ago. BID to manage diabetes type 2, she takes yogurt with this medication, which helps with stomach upset. Albuterol 90 mcg/spray MDI -two puffs every 4 hours PRN- inhaler to manage asthma exacerbation. Fluticasone Propionate 88 mcg/spray- BID to manage asthma YAZ- 1 pill every morning- for birth control and to manage PCOS Advil - 2 tabs. for menstrual pain and headaches. Allergies Penicillin – Rash, hives, last taken as a childhood. Cat – aggravates asthma symptoms. Patient denied food, seasonal, and latex allergy. Medical History Asthma: since childhood, takes albuterol, and Proventil. Diabetes type 2: diagnosed at age 24 years. Takes metformin and daily blood sugar checks in the mornings and results normally in 90s. PCOS: takes Drospirenone and ethinyl estradiol Hypertension: normal blood pressure readings. Near sighted and blurry vision- wears glasses to help with vision. - - - - - - - - - - -- - - - - - - - - Differential Diagnosis • Diabetic Neuropathy as evidence to decreased sensation on both right and left great toes and right heels. This is the most common complication of diabetic mellitus. This is a clinical syndrome that affect distinct regions of the nervous system, singly or combined (Vinik, Casellini, & Nevoret, 2018). The loss of sensation results in the loss of thermal and pain perception. • Polycystic Ovary Syndrome (PCOS)is an ovarian disorder characterized by hyperandrogenism, ovulatory dysfunction and polycystic ovaries (Legro, 2017). This diagnosis is because of patient’s history of dysmenorrhea and longer periods, and severe cramps, as a birth control was prescribed. • Acanthosis Nigricans (AN) is termed a common cutaneous conditions that can be a manifestation of systemic disease that is associated with insulin resistance, diabetes mellitus, obesity, internal malignancy, endocrine disorders, and drug reactions (Patel, Roach, Alinia, Huang, & Feldman, 2018). The patient presents with a dark discoloration around her neck, which is evidence of inability to manage insulin levels. References Legro, R.S. (2017). Evaluation and treatment of polycystic ovary syndrome. Retrieved on July 26, 2020 from https://www.ncbi.nlm.nih.gov/books/NBK278959 Patel, N. U., Roach, C., Alinia, H., Huang, W. W., & Feldman, S. R. (2018). Current treatment options for acanthosis nigricans. Vinik, A., Casellini, C., Nevoret, M. R. (2018). Diabetic neuropathies. Retrieved on July 26, 2020 from https://www.ncbi.nlm.gov/books/NBK279175 [Show More]

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