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need you to edit this work to decrease the turnin percentages rate. This is a health assessment for Tina Jones via Shadow health environment. All the school use the same program so all the students pretty as the avatar the same questions. The turnin percentages is 62% just fix the attached document but you can not change a lot the information because the documentation is based on my assessment and interview with the avatar. The turnin percentages also including Walden preprint form. Run a turnin report for me and try to decreased the percentages.
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Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: TJ
DOB: February 17
Age: 28
Gender: F
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.”
History of Present Illness (HPI):
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Ms. Jones has recently secured employment at Smith, Stevens, Stewart, Silver &
Company, requiring her to undergo a pre-employment physical examination before
commencing her new role. As of today, she reports no immediate health concerns. Her
last healthcare visit took place four months ago at Shadow Health General Clinic, where
she had her annual gynecological examination. During that visit, the gynecologist
diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives,
which she has been managing well.
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Ms. Jones also manages type 2 diabetes through a combination of diet, exercise, and
metformin, which she began taking five months ago. She reports no adverse effects from
her current medication regimen. She expresses that she is feeling healthy, actively
investing in her well-being, and eagerly anticipating the start of her new job.
Medications:
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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 (for headaches)
Ibuprofen: 600 mg PO TID prn (last taken for menstrual cramps 6 weeks ago)
Zantac: Stopped taking 2 months ago for heartburn (dose not specified).
Allergies:
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Penicillin: Rash
Denies food and latex allergies.
Allergic to cats and dust. Exposure to allergens results in a runny nose, itchy and swollen
eyes, and increased asthma symptoms.
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Past Medical History (PMH):
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Asthma was diagnosed at age 2 1/2, using albuterol inhaler when exposed to cats. Last
asthma exacerbation was three months ago, resolved with her inhaler. Last hospitalized
for asthma during high school, never intubated.
Diagnosed with Type 2 diabetes at age 24, started metformin five months ago. Initially
had some gastrointestinal side effects, which have since subsided. Monitors blood sugar
levels once daily in the morning, with an average reading of around 90. Managed
hypertension with diet and exercise, resulting in normalized blood pressure. No surgeries
in her medical history.
Gynecological and sexual history: Menarche at age 11, first sexual encounter at age 18
with male partners, identifies as heterosexual. Never been pregnant, last menstrual period
occurred two weeks ago. Diagnosed with polycystic ovarian syndrome (PCOS) four
months ago. After starting Yaz, her cycles have become regular, occurring every four
weeks with moderate bleeding lasting five days. In a new male relationship, sexual
contact has not yet occurred, but she plans to use condoms when it does. Tested negative
for HIV/AIDS and STIs four months ago.
Last Pap smear conducted four months ago, last eye examination three months ago, last
dental checkup five months ago. Negative PPD test approximately two years ago. Up to
date on childhood vaccines and received the meningococcal vaccine for college. Safety
practices include having smoke detectors installed at home, always using a seatbelt in the
car, and refraining from riding a bike. Use sunscreen. Firearms are present in her home,
securely stored in her parents’ room.
Personal/Social History:
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Never married, no children. Lived independently since age 19, currently residing with her
mother and sister in a single-family home but planning to move into her own apartment
in one month. Set to start a new position at Smith, Stevens, Stewart, Silver, & Company
in two weeks.
Enjoys spending time with friends, reading, attending Bible study, volunteering at her
church, and dancing. Actively involved in her church and has a strong family and social
support network. Family and church community play crucial roles in helping her manage
and cope with stress.
No tobacco uses. Had a history of cannabis use from age 15 to 21. Reports no recent use
of cocaine, methamphetamines, or heroin. Occasional alcohol consumption, typically 2-3
times per month when out with friends, is limited to no more than three drinks per
occasion. Typical meals include a frozen fruit smoothie with unsweetened yogurt for
breakfast, vegetables with brown rice or a sandwich on wheat bread or low-fat pita for
lunch, and dinner comprises roasted vegetables and a protein source. Snacks consist of
carrot sticks or an apple. No coffee intake but consume 1-2 diet sodas per day. No recent
foreign travel, and no pets. Engages in mild to moderate exercise four to five times per
week, including walking, yoga, or swimming.
Health Maintenance:
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Most recent Pap smear was conducted four months ago, with her last eye examination
three months ago and her most recent dental checkup five months ago. Had a negative
PPD test around two years ago. Up-to-date on childhood vaccines, including the
meningococcal vaccine for college.
Practices safety measures such as having smoke detectors at home, wearing a seatbelt in
the car, and not riding a bike. Use sunscreen. Firearms are present in her home, securely
stored in her parents’ room.
Significant Family History:
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Mother, aged 50, has hypertension and elevated cholesterol levels.
Father, who passed away in a car accident one year ago at age 58, had hypertension, high
cholesterol, and type 2 diabetes.
Brother, Michael, aged 27, is overweight.
Sister, Britney, aged 15, has asthma.
Maternal grandmother passed away at age 73 due to a stroke, with a history of
hypertension and high cholesterol.
Maternal grandfather passed away at age 78 due to a stroke, with a history of
hypertension and high cholesterol.
Paternal grandmother, aged 82, has hypertension and is still living.
Paternal grandfather passed away at age 65 due to colon cancer, with a history of type 2
diabetes.
Paternal uncle has a history of alcoholism.
No known family history of mental illness, other cancers, sudden death, kidney disease,
sickle cell anemia, or thyroid problems.
Review of Systems:
General:
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No current headaches, head injuries, or sudden visual changes, + 10 lbs weight loss, no
fever, chills, or fatigue reported.
HEENT:
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No complaints of eye pain, itchy eyes, redness, or dry eyes. Wears glasses, and last saw
an optometrist three months ago. No ear problems, change in hearing, ear pain, or
discharge. No change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or
rhinorrhea. No general mouth problems, changes in taste, dry mouth, pain, sores, issues
with gums, tongue, or jaw. No current dental concerns, last dental visit was five months
ago. No difficulty swallowing, sore throat, voice changes, or swollen lymph nodes.
Cardiovascular:
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No palpitations, tachycardia, easy bruising, or edema.
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Respiratory:
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No shortness of breath, wheezing, chest pain, dyspnea, or cough.
Abdominal/Gastrointestinal:
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No nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food
intolerance.
Genitourinary:
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No dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge, or itching.
Musculoskeletal:
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No muscle pain, joint pain, muscle weakness, or swelling.
Integumentary:
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Improved acne due to oral contraceptives. Skin darkening on the neck has stopped, and
facial and body hair have improved. A few moles are present, but no other hair or nail
changes.
Neurological:
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No dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or a
sense of disequilibrium.
Psychiatric/Psychosocial/Mental Health:
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Decreased stress and improved coping abilities. Denies current feelings of depression,
anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Wellgroomed, easily engaged in conversation, and is cooperative. Mood is pleasant. No tics or
facial fasciculation. Speech is fluent, with clear words.
Objective Data:
Physical Exam:
Vital Signs:
Height: 170 cm
Weight: 84 kg
BMI: 29.0
Blood Glucose: 100
RR: 15
© 2021 Walden University, LLC
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HR: 78
BP: 128/82
O2: 99%
T: 37.2°C
General:
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Ms. Jones is a pleasant, 28-year-old African American woman who is single and has
come in for a pre-employment physical. She is the primary source of her medical history
and provides information clearly and consistently. During the interview, she maintains
good eye contact, speaks coherently, and is alert and oriented. She sits upright on the
examination table without any signs of distress, displaying proper nourishment,
development, and hygiene.
Physical Examination Findings:
HEENT:
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Her head appears normocephalic and atraumatic. Her eyes display equal hair distribution
on lashes and eyebrows, with eyelids free from lesions, ptosis, or edema. The conjunctiva
is pink and clear, and the sclera is white. Pupils are equal, round, and reactive to light in
both eyes. Extraocular movements are intact without nystagmus. Mild retinopathic
changes are noted in the right eye. The left fundus shows sharp disc margins without
hemorrhages. Visual acuity with corrective lenses is 20/20 in both eyes. Tympanic
membranes are intact and have a pearly gray appearance, with a positive light reflex. She
hears whispered words bilaterally. Frontal and maxillary sinuses are non-tender to
palpation, and nasal mucosa is moist and pink, with a midline septum. The oral mucosa is
moist without ulcerations or lesions, and the uvula rises midline during phonation. The
gag reflex is intact, and dentition is without evidence of caries or infection. Tonsils are
graded as 2+ bilaterally. The thyroid is smooth without nodules and shows no signs of
goiter. There is no lymphadenopathy.
Respiratory:
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Her chest is symmetric with respiration and clear on auscultation, without coughing or
wheezing. Percussion reveals resonant sounds throughout. In-office spirometry results
show an FVC is 3.91 L and FEV1/FVC ratio is 80.56%.
Cardiovascular:
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Her heart rate is regular with S1 and S2 sounds, and there are no murmurs, gallops, or
rubs. Bilateral carotid pulses are equal and lack bruits. The PMI is located at the
midclavicular line, 5th intercostal space, with no heaves, lifts, or thrills. Peripheral pulses
are equal bilaterally, and capillary refill is less than 3 seconds. There is no peripheral
edema.
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Musculoskeletal:
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Strength is 5/5 in both upper and lower extremities, with no swelling, masses, or
deformities and full range of motion. There is no pain with movement.
Abdominal:
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The abdomen is protuberant and symmetric, with no visible masses, scars, or lesions.
Coarse hair is noted from the pubic region to the umbilicus. Bowel sounds are
normoactive in all four quadrants, and percussion is tympanic throughout. In terms of
palpation, no tenderness or guarding is observed, and there is no organomegaly. There is
no CVA tenderness.
Integumentary:
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Scattered pustules are present on the face and facial hair on the upper lip. Acanthosis
nigricans is observed on the posterior neck. Nails are free of ridges or abnormalities.
Neurological:
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Normal findings are noted for graphesthesia, stereognosis, and rapid alternating
movements bilaterally. Tests of cerebellar function show normal results. Deep tendon
reflexes (DTRs) are 2+ and equal in both upper and lower extremities. There is decreased
sensation to monofilament in bilateral plantar surfaces.
Diagnostic results: N/A Pre-employment physical
ASSESSMENT:
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Tina Jones returns for a follow-up/general physical examination. She is currently
prescribed metformin, Proventil, and Flovent. She now wears glasses after her vision
examination. Her sleep quality is good, and her diabetes is effectively controlled through
a combination of medication, a balanced diet, and regular exercise. She diligently
monitors her blood sugar levels and has gained confidence in her ability to interpret the
readings. She has initiated the practice of maintaining records of her asthma, proactively
avoiding triggers, and monitoring the usage of her rescue inhaler. In addition, Tina is in a
relationship and is currently using birth control, which has been successful in managing
her PCOS.
© 2021 Walden University, LLC
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