NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT Patient Initials: Tina Jones Age: 28 Gender: Female  SUBJECTIVE DATA:  Chief Complaint (CC) for NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMEN

NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

Patient Initials: Tina Jones Age: 28 Gender: Female 

SUBJECTIVE DATA: 

Chief Complaint (CC) for NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT patient: “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 (HPI) for NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT patient: Tina Jones comes into the clinic for a general physical exam. She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. She denies any acute concerns at this visit. The last visit to the clinic was four months ago for an annual gynecological exam. At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive drospirenone and ethinyl estradiol (Yaz). She states she takes the pill daily, at the same time each day. Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. She regularly monitors her blood glucose levels, checking once a day in the morning. She also has been keeping records of her asthma by monitoring her peak flow. The rescue inhaler was last used three months ago with a total of two uses in the past year 

Medications: Metformin: Started five months ago. 850 mg twice daily. Reports eating probiotic yogurt helps with side effects. Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. Drospirenone and ethinyl estradiol: one pill every day. Ibuprofen: 600 mg as needed for menstrual cramps 

Allergies: Ms. Jones has a penicillin allergy with a reaction of rash. She is allergic to cats and dust. These allergens aggravate her asthma symptoms, so she tries to avoid them. She denies any food allergies 

Past Medical History (PMH): Patient has history of diabetes which was diagnosed at age 24 and is on metformin, compliant with her blood glucose check. Patient was diagnosed with asthma at the age of 2.5 

Past Surgical History (PSH): Denies any surgical history 

Sexual/Reproductive History: She had menarche at the age of 11. She had her maiden sex at the age of 18. She identifies as heterosexual and only has sex with men. She denies ever being pregnant with her last monthly periods occurring a fortnight ago. She was also diagnosed with PCOS during her last physical exam, which occurred 4 months ago. After starting on the prescription drug Yaz, her cycles have become regular accompanied with bleeding that is moderate and which lasts five days. No sexual intercourse with the new boyfriend yet. No sexual transmitted diseases as per the last text done 4 months ago. 

Personal/Social History: Ms Jones reported drinking about 6 drinks/day. Patient denies any illegal use of drugs. Just graduated from college with a BA. 

Health Maintenance: Patients diabetes is well controlled, does exercise daily, eats fine. Though feels exhausted at the end of the day. 

Immunization History: Up to date with childhood immunization record. 

Significant Family History: There is a family history of diabetes – father and paternal uncle. Family also has history of hypertension with grandmother and father. 

Review of Systems  

General: Ms. Jones is sitting comfortably on the examination table, in no acute distress. No current complaints or recent illness. She appears well-nourished and dresses appropriately. Reports recent weight loss. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C 

HEENT: Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. She wears corrective