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Tina Jones Health History Essay

Tina Jones Health History Essay

Tina Jones Health History

Identifying Data

Ms. Jones is a pleasant 28-year-old, single, African American, female. She presents to the office today for a physical examination and with a chief complaint of right foot pain after a recent injury. She is the primary source of history obtained in addition to the use of her available medical record. She is able to maintain good eye contact and clear speech throughout the interview process, as she provides all information freely.Tina Jones Health History Essay


General Survey

Ms. Jones is alert and oriented, with relaxed posture during the assessment process. Her mood appears to be stable, and she does not appear to be in any distress. Her immediate and remote memory appear to be intact. She appears to have good hygiene and is dressed appropriately for the current weather and occasion.

Chief Complaint: “I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!”

History of Present Illness

Ms. Jones presents today for a physical examination and with report of a scrape to the ball of her right foot. She reports that she obtained the scrape 1 week ago when she tripped going down the stairs and scraped her bare foot on the edge of the step. She reports bleeding at the time of injury, and shares that she has been washing the wound with soap and water twice daily (morning and night), and that she has been using Neosporin prior to keeping it bandaged. She added that she sometimes uses peroxide and then rinses the area when it is irritated. She reports that the scrape is not healing on its own, “is not looking well”, and is causing her pain. Her current pain level is a 7/10, and she describes the pain as “throbbing” and “sharp” when weight is applied. She reports that her entire right foot feels some pain, but the pain is the worst at the center/ball of her foot. She added that the pain also radiates up her ankle. She has not been able to walk due to this pain. She has been taking Tramadol 100 mg three times daily for pain, but feels that this only alleviates the pain for a few hours. She reports that the area has been red and swollen with noted pus, heat, and increased pain over the last 2 days ago. She denies noted odor.Tina Jones Health History Essay


• Tramadol 50 mg tablets. Taking 2 tablets (100 mg Total) 3 times daily for pain.
• Proventil Inhaler 90 mg 2- 3 puffs 2-3 times per week for asthma symptoms.
• Advil 200 mg tablets. Taking 3 tablets (600 mg Total) up to 3 times daily for menstrual cramps.
o Patient self-discontinued Metformin and birth control pill use 3 years ago.
o She denies use of any other vitamins, supplements, or additional OTC medications.Tina Jones Health History Essay


• Penicillin (Rash/Hives. Last occurring in childhood)
• Cats (Itchy eyes, sneezing, wheezing)
• Dust (Itchy eyes, sneezing, wheezing)
o Denies Food Allergies.
o Denies Latex Allergies.
o Denies Seasonal Allergies.

Medical History

• Type 2 Diabetes: Diagnoses at age 24. Has a glucometer, but does not currently monitor her blood glucose due to feeling it is a hassle. Not currently taking prescribed medication. Was taking Metformin when first diagnosed but discontinued taking this 3 years ago due to not liking it. Does not follow a specific diabetic diet. Tries to make healthy choices. Avoids excess carbohydrate and sugar intake (drinks diet versus regular soda). Does not monitor her salt intake. She reports increased appetite, thirst, and water intake. Reports unintentional weight loss of 10 lbs. over the last month. She also reports more frequent urination.

• Asthma: Diagnosed as a child at age 2. Reports chest & throat tightness, wheezing, and feels that she can’t take in enough air into her lungs during attacks. Reports dust, cats, and exercise (such as running up the stairs) make breathing worse. Reports showering helps with symptoms when exposed to cats. She reports that her asthma attacks are rare, and that the last attack resulted in hospitalization when her inhaler was not working at age 16. Reports using a prescribed Proventil Inhaler 90 mg 2- 3 puffs 2-3 times per week as needed for asthma symptoms.Tina Jones Health History Essay

Health Maintenance

• Report that she is currently up-to-date on her immunizations. Received all childhood vaccinations. Last tetanus booster was about 1 year ago. Last PPD test was a couple of years ago. Last HPV test was a couple of years ago. Denies having a varicella vaccine dt having chicken pox as a child. Denies having a diphtheria vaccine. Denies getting an annual flu vaccine (with last received 6 years ago) due to feeling that they are ineffective.
• Last physical was 2 years ago. Reports recent increase in stress and feeling of exhaustion at end of day. Denies changes in sleep status (aside from when father died last year). Reports that she has not been sleeping well lately d/t foot pain. Denies Depression.
• Reports declining vision over the last few years. Last eye exam was a child. Reports that she has been experiencing headaches while studying.
• Reports brushing her teeth twice daily (AM & PM). Last dental exam was a few years ago. Tina Jones Health History Essay
• Reports increased facial and body hair growth. Medical record indicated dx of PCOS.
• Reports irregular menstrual cycle occurring from once monthly to every six months. Reports heavy vaginal flow and bad cramping, for which she uses Advil with minimal effect. Not currently sexually active. Report prior birth control use for 3 years during last relationship w/ male partner. Denies current condom use.
• Denies daily exercise but reports an active job which requires her to be on her feet.

Family History

• Significant for: Diabetes, Hypertension, Hypercholesterolemia
• Denies family use of alcohol / illicit drugs.
• Denies family history of obesity, thyroid issues, substance abuse, headaches.

• Mother: Living. 50 y.o. High cholesterol & BP
• Father: Passed last year at 58 y.o. in a car accident. High BP & Chol & DM.
• Maternal GF “Poppa”: Passed via Heart attack at 80 y.o.. BP & Cholesterol issues. Maternal GM “Nana”: Passed 5 yrs ago at 73 from a stroke: High BP & Chol
• Paternal GF: “Grandpa Jones”: Passed mid-60’s of colon cancer.
• Paternal GM “Granny”: Living. 82 y.o. on unknown RX for ? BP ? Chol.
• Paternal Uncle: Alcoholic
• Sister “Britney”: 14 y.o. w/ asthma no attacks. Also has allergies “hay fever”, which led to an ER visit for a breathing treatment. Tina Jones Health History Essay
• Brother: 25 y.o. “heavy guy” no health problems

Social History

• Denies smoking tobacco
• Denies 2nd hand smoke exposure
• Reports occasional social ETOH intake (1-2 drinks/wk.)
• Reports prior Marijuana use in her 20’s.
• Current support system: Family, friends, Baptist church group
• Currently unable to work d/t injury.
• Profession: Supervisor at Mid-American Copy & Ship.

Review of Systems:

General: Ms. Jones is a 28 y.o. well-appearing African American female. She reports occasional tiredness and fatigue. Reports that she has been experiencing a fever over the last 2 days since her foot injury. She appears to have good hygiene and calm demeanor. She was able to answer all questions appropriately.

HEENT: Reports occasional headaches while reading. Reports recent blurred vision and decline in vision. Does not wear corrective lenses. Last eye exam was in childhood. Denies current change in hearing. Denies decline or change in sense of smell. Denies dental problems. Last dental exam was several years ago. Denies sore throat.

Denies general breast problems or pain.

Denies current breathing problems.

Denies palpitations or noted ease in bruising.

Denies nausea, change in bowel movements, or diarrhea.Tina Jones Health History Essay

Denies painful or difficult urination. Reports awakening to urinate at night.

Reports irregular menstrual periods that occur over 6 to 24 weeks. Reports heavy blood flow and cramping that is treated with OTC medication at home. Denies recent sexual activity. Reports prior sexual activity, with male partner 2 years ago. Has had a total of 3 prior sexual partners. Denies current oral or hormonal birth control use. Reports prior condom and oral contraception use a couple of years ago. Discontinued contraception use whenshe was no longer sexually active. Unsure of prior STI testing. Last pap smear was 4 years ago. Denies prior pregnancies.

Denies muscle or joint pain.

Denies depression. Reports history of intermittent situational anxiety. Denies currently altered sleep pattern.

Denies lightheadedness, tingling, loss of sensation, or seizures.

Denies history or frequent skin rashes. Reports rash with Penicillin use. Reports recent excessive facial and body hair growth.Tina Jones Health History Essay

Denies endocrine issues or hormonal disorder. Medical record indicated prior diagnosis of PCOS.

Objective Data

Height: 5′ 7″
Weight. 90 kg
BMI: 31.0
Blood Pressure: 142/82
Heart Rate: 86
Respiratory Rate: 19
Oxygen Level: 99% on Room Air
Temperature: 101.1 Oral
Blood Glucose: 238
Wound Measurement: 2 cm x 1.5 cm. 2.5 cm deep

Please use the patient information provided below for this paper.

This assignment assesses intended course outcome(s)

#4 Use information found in patients’ health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient’s individual health promotion and disease prevention needs Tina Jones Health History Essay

Students will use the information found in Tina’s history, physical exam, and problem list to formulate an individualized health promotion and disease prevention plan of care. Recommendations should be evidence-based and from credible sources. The readings in module eight contains some suggested sources for obtaining health and screening recommendations for your patient.

The plan for addressing the health promotion and disease prevention needs for your patient should include:


– Age, gender and race of patient

– Education level (health literacy)

– Access to health care

Insurance/Financial status

– Is the patient able to afford medications and health diet, and other out-of-pocket expenses?

Screening/Risk Assessment

– Identified health concerns based on screening assessments and demographic information


– What is the patients activity level, is the environment where the patient lives safe for activity

– Nutrition recommendations based on age, race gender and pre-existing medical conditions Tina Jones Health History Essay

– Activity recommendations

Social Support

– Support systems, family members, community resources

Health Maintenance

– Recommended health screening based on age, race, gender and pre-existing medical conditions

Patient Education:

– Identified knowledge deficit areas/patient education needs (medication teaching etc).

– Self-care needs/ Activities of daily living

* The paper should be written and referenced in APA format and be no longer than 4 pages (excluding cover page and references).

Your paper will be evaluated based on the following criteria:Tina Jones Health History Essay


Level 3

Level 2

Level 1



Includes age, race and gender of patient

Missing one data item

Missing 2 or more data items

Insurance/Financial status


Includes information regarding patient’s insurance status and ability to afford medications and other out-of-pocket expenses

Missing some information regarding insurance status and ability to pay for medications and other out-of-pocket expenses.

Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses Tina Jones Health History Essay

Screening /risk assessment


Identifies health concerns based on screening assessments and demographic information.

Missing some information regarding health concerns, by excluding information from screening assessments and demographics

Health concerns are not identified due to information missing from screening assessments and demographics



Completely asses patient’s nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions

Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions

Most of the information regarding the patient’s nutrition and activity levels are missing, recommendations are missing or not based on the patient’s age, race, gender and pre-existing medical conditions

Social support


Identifies support systems such as family members and community resources

Missing some information regarding support systems such as family members and/or community resources Tina Jones Health History Essay

Little to no information regarding social support

Health Maintenance


Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions

Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions

Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions

Patient Education


Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living

Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living

Lacks identification of knowledge deficit areas/patient education needs. Does not consider self-care needs or activities of daily living.Tina Jones Health History Essay

Organization, spelling and grammar, APA


Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA

Organized and easy to read, few spelling or grammar mistakes, few errors in APA

Disorganized, difficult to read, many spelling and grammar errors mistakes. Does not use APA

Overall score






( 0-23)

Health History

Student Documentation

Model Documentation

Identifying Data & Reliability

Tina Jones is a 28 year old African american female AOX4. Pt is reliable historian

Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.Tina Jones Health History Essay

General Survey

Alert and oriented X4. Feels tired because she was just coming from her other job.

Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.


Reason for Visit

Presenting to shadow health hospital clinic for a complete health assessment for a pre-employment physical.

“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

Tina Jones is a 28year old African America female with a history of diabetes and Asthma presenting to get a complete health assessment for a pre-employment physical.

Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.Tina Jones Health History Essay


Metformin 850mg twice daily Yaz birth control daily in the morning Flovent MDI twice daily proventil 90mcg/spray 2 puffs as needed for wheezing

• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)Tina Jones Health History Essay


Penicillin- Rash, hives cats- sneezing, itchy watery eyes, asthma exacebation No Known food allergies No latex allergies

• Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.

Medical History

Asthma- diagnosed at age 2 1/2 Diabetes Type 2 – diagnosed at 24 was on metformin but stopped due to side effects

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.Tina Jones Health History Essay

Health Maintenance

Has been eating healthy and trying to stay active by walking 30-40 mins two times per week and also swimming once a week

Last Pap smear 4 months ago. Last eye exam three months ago. Last dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.

Family History

-Father died 2 1/2 ears ago in a car accident. History of high blood pressure,type 2 diabetes and high cholesterol -Mother is still alive. has history of hypertension and high cholesterol. -Brother is overweight -Sister has asthma Tina Jones Health History Essay

• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Social History

she does not have any children, has never been pregnant and has never been married. she lives with her mother and sister. currently works but is hoping to start a new jop as an accounting clerk at smith, stevens, steward silver company. drinksa alcohol ocassionally when she goes out with friends Tina Jones Health History Essay

Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.Tina Jones Health History Essay

Mental Health History

Denies any history of depression or suicidal thoughts. denies any problems with mood. no overall safety concerns.

Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear Tina Jones Health History Essay

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