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Shadow Health Comp Assessment With Complete Solution
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Shadow Health Comp Assessment With Complete Solution
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Shadow Health Comp Assessment WithComplete Solution
Identifying Data & Reliability -Ms. Jones
-28-year-old
-African American
-single
-religious preference
-Education
-Occupation: Smith, Stevens, Stewart, Silver & Company
-Occupational history
-woman
-presents for a pre- employment physical. -She is the primary source of the history. -
offers information freely and without contradiction.
-Mrs. Jones Reliable historian
General Survey Alert/oriented
-seated upright
-well-nourished
-well-developed
-dressed appropriately
-good hygiene.
Reason for Visit SEE HPI
history of present illness HPI: "pre-employment physical" prior to initiating
employment."
Patient Description of current overrall health: "feels healthy, is taking better care of
herself than in the past"
Medications + Fluticasone propionate 110 mcg 2 puffs BID, Metformin, 850 mg PO
BID, Drospirenone, ethinyl estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H
prn, Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn
(menstrual cramps)
-using topical antifungals, anti-itch creams, steroid topical ointments, eye/ear/sublingual
drops, Benadryl, herbs gingko/garlic/primrose.
Allergies +Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes)
-Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex
allergies.
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