Comprehensive Health History Discussion Paper

Posted: December 28th, 2022

Comprehensive Health History Discussion Paper

Chief Complaint: “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: Ms. Jones states that she just accepted a position as an accounting clerk and that she was required to undergo a pre-employment physical exam in order to begin working at her new role. As of right now, she is not suffering from any form of serious health problem. Over four months have passed since her last doctor’s visit, during which she was diagnosed with PCOS. A hormonal contraceptive was prescribed, and she reports that she is experiencing no adverse affects and is handling the prescription well. When Ms. Jones went in for a previous checkup years ago, she was told that she had type 2 diabetes. On being questioned about her diabetes management, she responded that she keeps her glucose levels in check with exercise, nutrition, and medication. It has been five months since she began taking Metformin, which she is presently using. She claims that she has seen no adverse effects from the medicine and that her body has responded well to it generally. She claims to be in good health and that she merely came to the clinic to receive a checkup for work purposes Comprehensive Health History Discussion Paper.

ORDER A PLAGIARISM-FREE PAPER HERE

Current Medications:

Metformin 2X daily for type 2 diabetes YAZ daily for polycystic ovarian syndrome

Albuterol Inhaler 90mcg per spray, as required for asthma attacks

Allergies:

Penicillin: rash

Allergic to cats and dust. Whenever she is subjected to these allergens, she complains of having a runny nose, itchy and swollen eyes, and worsening of her asthma symptoms.

Denies food and latex allergies Comprehensive Health History Discussion Paper

 

Past Medical History

The diagnosis of asthma in Tina Jones was made when she was two and a half years old. She utilizes an Albuterol inhaler to assist manage her asthma, which has shown to be effective. In the event of an asthma attack, she will inhale two or three puffs. Going up the stairs or doing an exercise that takes a lot of oxygen, dust, and cat fur are all things that cause her asthma episodes. During high school, she had an asthma attack that necessitated her hospitalization. She reported that she was not intubated while in the hospital.

It has been roughly two weeks since Ms. Jones last had a menstruation. The doctor diagnosed her with polycystic ovarian syndrome four months ago. Because of this, she began using YAZ to aid her in her recovery. Each month, she gets a regular, normal menstruation. During her visit to the doctor, she was tested for HIV/AIDS as well as sexually transmitted diseases (STDs), and the results came back negative. The most recent Pap smear was also performed on that appointment. It was five months ago that she underwent dental and eye examinations.

The patient claims that she has also been diagnosed with high blood pressure. She claims that she maintains control over her blood pressure with nutrition and physical activity.

She was diagnosed with type 2 diabetes when she was 24 years old, and she started taking Metformin 5 months ago.   Her blood glucose levels are monitored on a daily basis, and her numbers are normally around 90.

Her current immunizations include Tetanus Booster. Neither the flu vaccination nor the HPV vaccine is current. She claims that she has had all of her childhood vaccinations, and that she received her meningoccal vaccine when she started college.

Family Health History

Ms. Jones notes that type 2 diabetes, stroke, colon cancer, asthma, high cholesterol, and high blood pressure are all conditions that run in her family. Her father, who was 58 years old at the time of his death, was killed in a car accident last year. His medical history revealed that he suffered from hypertension and type 2 diabetes. Her mother is presently 50 years old and suffers from high cholesterol and hypertension. Her brother is 27 years old, and her younger sister is 15. Her 15-year-old sister has also suffered with asthma in the past. Her 27-year-old brother is obese. Her paternal grandpa died of colon cancer when he was 65 years old; he also had a history of type 2 diabetes. Her paternal uncle has a history of alcoholism. When she was 73 years old, her maternal grandmother died after suffering a stroke. She had a history of hypertension and elevated cholesterol. Her maternal grandpa, who died at the age of 80, also died as a result of a stroke Comprehensive Health History Discussion Paper.

Social History

Ms. Jones is now living with her mother and sister in a single-family household but she will be moving into her own apartment within one month. She will begin working at her new job in two weeks. She feels she has control over her health and considers herself to be a pretty healthy individual. Her leisure activities include weekend get-togethers with her friends, social drinking, but she does not smoke or use any illegal drugs of any kind.

She is an enthusiastic part of her local church, to which she attends every Sunday. She also spends the most of her Wednesdays attending bible study. She likes taking part in community activities such as volunteering. She does her exercise by walking, swimming, or doing yoga four to five times a week. She informed me about her regular diet, which she described as nutritious and well-balanced. She consumes the standard three meals every day. She expresses no worry about mental health issues, and there is no history of mental health issues in her family.  As contrast to previous periods, she claims that she is less stressed now, and that her sleep is better Comprehensive Health History Discussion Paper.

Review of Systems

HEENT: Head: denies headache. Denies history of head injury. Eyes: Denies injury, dry eye, itching, or redness. Patient wears contacts. Ears: denies problems hearing. Denies hearing changes. Denies pain or discharge. Nose: denies change in smell. Denies sinus pain or pressure. Denies runny nose. Throat: denies mouth issues. Denies issues with tongue, teeth, or gums. Denies swallowing issues.

Respiratory: denies cough, shortness of breath, or chest pain.

CV: Denies palpitations or tachycardia, or edema

GI: Denies nausea or vomiting. Denies diarrhea or pain in the abdomen.

GU: Denies pain on urination, Reports frequent urination at night time.

Musculoskeletal: Denies muscle pain, weakness, or swelling.

Neuro: Denies dizziness, loss of coordination, seizures, lightheadedness, or loss of sensation.

Psychiatric: denies depression, anxiety or other mental problems

ORDER  HERE

Physical Exam

Vital signs

Height: 170 cm

Weight: 84 kg

BMI: 29.0

Blood Glucose: 100

Blood Pressure: 128/82

Pulse: 78

Pulse Ox: 99%

Temperature: 37.2C

Respirations: 15/BPM

 

HEENT: The head is normalocephalic and unaffected by trauma. Eyes: There are no lesions, edema, or ptosis seen in either of the eyes. Pink conjunctiva, no lesion, white sclera, and no bleeding. Pupils are equal in size, quick in movement, round in shape, and receptive to light. There is no nystagmus. She got a 20/20 vision in the Snellen test while wearing her corrective glasses. Ears: The tympanic membrane is pearly and grey in color. Positive response to light. Can hear whispers. When the sinuses are palpated, they are not tender. Nose: The nasal mucosa is moist and pink. The septum is in the middle of the body with no deviation. Mouth: Mucosa of the oral cavity is moist. There are no ulcers or lesions. The gag reflex is a positive response. +2 tonsils. Throat: Moist. The thyroid is smooth and free of nodules. There is no lymphadenopathy.

Respiratory: The oxygen saturation of the patient is 99 percent while breathing room air. Her lung capacity is 3.91L and ratio is 80.56 percent. The chest wall is symmetrical bilaterally, normal expansion bilaterally. Breath sounds are normal and he is clear to auscultation.

CV: + 2 pulses on palpation, no thrills. s1 and s2 heard, no rubs, murmurs, or gallops.  capillary refill time is less than three seconds. No edema. Comprehensive Health History Discussion Paper

GI: symmetrical abdomen with no visible lumps, protuberant skin. Coarse hair from pubis to umbilicus. Bowel sounds can be heard in all four quadrants. No guarding or tenderness. The aortic artery does not produce any bruit. The liver span is 7cm, and the abdomen is tympanic. Abdomen is soft and nontender. No pain on deep palpation. Palpable liver. The spleen is not palpable, and neither the right nor left kidneys are palpable.

Musculoskeletal: No edema, deformity, or lumps in the upper or lower extremities bilaterally. 5/5 strength in both extremities. Full ROM.

Neurologic: Normal cerebellar function tests. Normal stereognosis, graphesthesia, and rapid alternating movements bilaterally. DTRs 2+ and equal bilaterally in both extremities.

Assessment

Ms. Tina Jones walks in for a regular physical examination. The medications metformin, Proventil, and Flovent are currently being used by her. Following an eye examination, she now wears glasses. As a result of medicine, nutrition, and exercising, her diabetes is under control. She checks her blood glucose levels on a regular basis and seems more confident in her understanding of the significance of the readings. Regular monitoring of the usage of her rescue inhaler and measuring her peak flow are two of the measures she has taken to control her asthma.

Diagnosis – [N/A] Pre- employment physical

PLAN:

[N/A] Pre- employment physical

The patient expresses her knowledge of the exam and the processes that were described to her prior to the evaluation. At this moment, the patient states that she has no more issues. Comprehensive Health History Discussion Paper

Comprehensive Health History and Physical Examination Guidelines: Advanced Health Assessment

 

Each student will complete a comprehensive health history and physical examination write-up following the format from Seidel’s Guide to Physical Examination 9th edition (Ball et al., 2019) using all of the information from Tina Jones, the virtual patient in Shadow Health. The written assignment is documentation of the findings and should demonstrate application of course content and follow the criteria in the grading rubric.

 

Content Using the virtual patient “Tina” perform a health history and physical exam.	Grade percentage
Chief Complaint and History of Present Illness	5%
Past Medical and surgical History	5%
Medications and Allergies	5%
Family History	5%
Social History	5%
Review of Systems (see page 811 Seidel for example)	15%
Physical Examination ( include only objective findings determined by the ROS in other words FOCUSED physical)	40%
Assessment and Plan	5%
Utilizes appropriate terminology	5%
Follow appropriate format	10%
Total Percent	100%