Comprehensive Assessment: Tina Jones (Shadow Health study guide)

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Tina Jones is a 28 year old African America women. She came into the clinic for a physical exam. She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. She is required... to have a physical exam for her health insurance. Tina's health history was taken, a physical assessment was done and a plan of care was made. Health History Health history is a very important part of assessment for practitioners. When interviewing the patient the practitioner is able to get a health history and the history of the patients chief complaint. Through the interview process the practitioner is als o able to find out what the patient believes is most important about their health (Bickley, 2013). Tina is a 28 year old African American women. She is in the clinic today for a physical exam for her new job. She is the primary source of health history. Tina's speech is clear and coherent. She maintains eye contact throughout the interview. Tina is alert and oriented. She is well-developed and dress appropriately with good hygiene. She does not appear to be in any distress. Tina is allergic to cats, she states that she tries to avoid cats but when she is around them her asthma "acts up" (T. Jones, Shadow Health Interview, February 13, 2016). She states that she has tightness in her chest and wheezing. She is allergic to PCN. She states that she "got a ra sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). She denies any food and latex allergies. She denies having any recent allergies to dust or pol len. She states that she has had problems in the past but they have not h appened in "a while" (T. Jones, Shadow Health Interview, February 13, 2016). She states that her daily inhaler has helped with her environmental allergies. [Show More]

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