course material

1. Comprehensive Health History Discussion Paper
Comprehensive Health History Discussion PaperChief 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 HERECurrent Medications:Metformin 2X daily for type 2 diabetes YAZ daily
for polycystic ovarian syndromeAlbuterol Inhaler 90mcg per spray, as required for asthma
attacksAllergies:Penicillin: rashAllergic 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 HistoryThe 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

2. 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 HistoryMs. 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
HistoryMs. 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
SystemsHEENT: 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 edemaGI: 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
problemsORDER HEREPhysical ExamVital signsHeight: 170 cmWeight: 84 kgBMI:
29.0Blood Glucose: 100Blood Pressure: 128/82Pulse: 78Pulse Ox: 99%Temperature:

3. 37.2CRespirations: 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 PaperGI: 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.AssessmentMs.
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 physicalPLAN:[N/A] Pre-
employment physicalThe 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 PaperComprehensive
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. ContentUsing the virtual patient
“Tina” perform a health history and physical exam. Grade percentageChief 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

4. 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%