COMPREHENSIVE HISTORY AND PHYSICAL EXAM WRITE UP
PART 2
Robin Beam, RN
NURSE 360 Health Assessment
University of Maryland University College
Fall 2016
Dr. An’Nita Hebron
Comprehensive History & Physical Exam Write
...
COMPREHENSIVE HISTORY AND PHYSICAL EXAM WRITE UP
PART 2
Robin Beam, RN
NURSE 360 Health Assessment
University of Maryland University College
Fall 2016
Dr. An’Nita Hebron
Comprehensive History & Physical Exam Write Up, Pt. 2
Health History
Ms. Tina Jones is a 28-year old African American woman who presents for a preemployment physical. She is the primary source of history. She is alert and oriented to self,
time, place and situation. Her mood is pleasant. Her language is fluent and speech is clear. She
maintains eye contact throughout the interview. She is seated in an upright position on the
examination table. She is neatly dressed, has good hygiene and appears well-nourished. She is
not in any distress.
Ms. Jones states that her last health exam was four months ago, when she received a
gynecological exam. She was diagnosed with polycystic ovarian syndrome and prescribed oral
contraceptives at that visit. She takes Yaz oral contraceptives by mouth once a day and is
tolerating it well. She reports that her menstrual cycles are regular with moderate bleeding
lasting five days since taking Yaz. During her gynecological visit, she had a pap smear and tested
negative for STI’s and HIV. She states that she is involved in a new heterogeneous relationship
and plans to use condoms with sexual activity.
Ms. Jones has type 2 diabetes. She controls her diabetes with diet, exercise and
Metformin 850 mg by mouth twice a day, which she started taking again five months ago. She
monitors her blood glucose once every morning. She controls her hypertension with diet and
exercise as well.
At the age of 2.5 years, Ms. Jones was diagnosed with asthma. Her last hospitalization
due to asthma was while she was in high school. She has never been intubated. She managers
her asthma with Albuterol 90 mcg/spray MDI 2 puffs every four hours as needed and Fluticasone
propionate 110 mcg 2 puffs twice a day. Her last asthma exacerbation was three months ago.
Ms. Jones takes Ibuprofen 600 mg by mouth as needed for menstrual cramps. She also takes
Acetaminophen as needed for
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