Grand Canyon University - NRS 434VN 430VWeek 4_ Comprehensive Assessment _ Completed _ Shadow Health.

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5/2020 Week 4: Comprehensive Assessment | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/6738271 1/6 Week 4: Comprehensive Assessment Results | Completed Health Assessme... nt - GCU - March 2020, nrs-434vn Return to Assignment (/assignments/321056/) Documentation / Electronic Health Record Vitals Student Documentation Model Documentation Vitals B/P - 128/82mmHg HR - 78bpm RR - 15cpm T - 37.2c SpO2 - 99% weight - 185lb • Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F Health History Student Documentation Model Documentation Identifying Data & Reliability Ms Tina, 28 year old African American, female, plesant, calm and cooperative. Patient is aware of her health and up to date on her care. Ms. Jones is a pleasant, 28-year-old African American single wom who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and with contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey Patient looks healthy with no abnormality detected during inspection. Calm, not anxious, afebrile, anicteric, undertands and responds to questions appropriately. patient wears glasses for near sightedness. Ms. Jones is alert and oriented, seated upright on the examinatio table, and is in no apparent distress. She is well-nourished, welldeveloped, and dressed appropriately with good hygiene. Reason for Visit Patient is here for a complete health assessment for pre-employment physical. "I came in because I'm required to have a recent physical exam f the health insurance at my new job." Your Results Turn In (/assignment_attempts/6738271/choose Lab Pass (/assignment_attempts/6738271/lab_pass.p Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Student Survey Documentation This study source was downloaded by 100000784424693 from CourseHero.com on 03-31-2021 15:04:53 GMT -05:00 https://www.coursehero.com/file/68089268/Week-4-Comprehensive-Assessment-Completed-Shadow-Healthpdf-2pdf/ This study resource was shared via CourseHero.com 4/25/2020 Week 4: Comprehensive Assessment | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/6738271 2/6 Student Documentation Model Documentation History of Present Illness She is diabetic and glucose is well controlled. Patient is also asthmatic and has PCOS Ms. Jones reports that she recently obtained employment at Smi Stevens, Stewart, Silver & Company. She needs to obtain a preemployment physical prior to initiating employment. Today she de any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow He General Clinic. Ms. Jones states that the gynecologist diagnosed with polycystic ovarian syndrome and prescribed oral contracepti at that visit, which she is tolerating well. She has type 2 diabetes which she is controlling with diet, exercise, and metformin, which just started 5 months ago. She has no medication side effects at time. She states that she feels healthy, is taking better care of he than in the past, and is looking forward to beginning the new job [Show More]

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