Ms. Jones is a 28-year-old who has an African-American ethnicity. She has visited the clinic to seek a complete health assessment, which is a requirement before securing her new employment. This paper will present the key findings of Ms. Jones’ comprehensive assessment. The findings will guide the development of an individualized and evidence-based plan of care to promote patient’s health through education and counseling. The self-care nursing model by Dorothea Orem and Health People 2020 will be considered during the formulation of the plan of care.Comprehensive health assessment.
Synthesis of Subjective Data
Chief Complaint (CC): “I came in because I’m required to have a recent physical exam for the health insurance at my new job.”
Health History
Current Health Status
Ms. Jones has secured a new job at the Smith, Stevens, Stewart, Silver, and Company. A pre-employment physical examination is required to allow the company to issue her with health insurance. She had visited Shadow Health Clinic four months ago for her annual gynecologist exam. Ms. Jones was diagnosed with the polycystic ovarian syndrome (PCOS) during the clinic visit. Consequently, the gynecologist prescribed her oral contraceptives, which have demonstrated a high degree of efficacy. She was previously diagnosed with type 2diabetes, which is managed through metformin medication and a healthy lifestyle, including taking a balanced diet and exercising regularly. The client has been taking metformin medication in the past five months and has not reported any side effects. She describes her health status as generally good. She also claims to be in a better position to take care of herself than in the past. As a result, she is ready for the new job at the Smith, Stevens, Stewart, Silver, and Company.Comprehensive health assessment.
Allergies: Ms. Jones reports various allergic reactions. Penicillin causes a rash. She is also allergic to dust and cats. However, she denies food and latex allergies. She experiences multiple symptoms, including runny nose, and itchy and swollen eyes upon being exposed to allergens. Additionally, her asthma symptoms worsen. She manages these allergic reactions by moving from the place with the allergens, bathing, or using a resue inhaler. Comprehensive health assessment.
Medications: The client is currently taking different medications to manage various illnesses.
Medical History
The client was diagnosed with asthma at the age of 2 ½ years. The asthma symptoms worsen upon being exposed to triggers in particular upon being around a cat. She uses an albuterol inhaler in the event of an asthma exacerbation. She experienced the last asthma attack three months ago. She used her inhaler to manage the situation. The last hospitalization due to asthma was when she was in high school. Nonetheless, the client has never been intubated. Secondly, she was diagnosed with type 2diabetes at the age of 24. She started used metformin medication to manage her blood-sugar levels 5 months ago. She monitors her blood sugar levels every morning. Her readings range at around 90. Furthermore, Ms. Jones has a history of hypertension that normalized following lifestyle modifications, including taking a healthy diet and exercising regularly. She denies any surgeries. She had her first sexual encounter when she was 18 years old. Her sexual partners were heterosexual. She has never been pregnant. She had her last menstrual period in the previous 2 weeks. Ms. Jones was also diagnosed with PCOS in the last four months. The client reports a new male relationship although no sex has been initiated. She anticipates using condoms during sexual intercourse.Comprehensive health assessment.
Health Maintenance
Ms. Jones undertakes various activities to maintain her health. Her last pap smear test was performed in the past four months. She also had her last eye and dental exam three and five months ago, respectively. She also received tetanus in the previous years
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