RUNNING HEAD: PATIENT ANALYSIS AND TEACHING TOOL 1Final Project: Patient Analysis and Teaching Tool Jacqueline Blount Southern New Hampshire University NUR-325-X2034
PATIENT ANALYSIS AND TEACHING TOOL 2 Introduction Tina Jones is a 28 year old African-American female who presents to the Shadow Health Clinic for a pre-employment physical to attain health insurance at her new job. She is scheduled to begin work as an accounting clerk at the accounting firm Smith, Stevens, Stewart, Silver & Company in two weeks. Ms. Jones present to the clinic independently and is the primary source of information for this assessment. She answers all questions freely with clear and coherent language utilizing the English language. Ms. Jones is alert and orient, and in no apparent distress,she presents seated upright on the examination table. She appears well-nourished, well-groomed and appropriately dressed. When asked about her general health she stated that “All of my health stuff is a lot better now. I feel like my diabetes is in control, I'm in better shape. . . I'm eating healthier. I'm less stressed. Things are going really well”. Her past medical history includes asthma, type 2 diabetes mellitus and polycystic ovarian syndrome. Ms. Jones current health maintenance is as follows. Her last annual exam and physical was five months ago, at this time she was prescribed Metformin, to gain better control of her diabetes, this was also around the same time that she began to modify her diet and exercise regime. Her last dental appointment was 5 months ago she reports that she was told that “her teeth look good”. Her last eye examination was three months ago at his time she was prescribed glasses for myopia. Her last gynecological examination was 4 weeks ago, at this time she had a pap smear and underwent testing for sexually transmitted diseases and infections. She reports a 10 lb. weight loss for whichshe credits to nutritional changes and exercise. She was first diagnosed with asthma at the age of 2 ½ years of age, she reports that her asthma is well-controlled with the use of her daily inhaler which is fluticasone propionate, 110 mcg, she uses 2 puffs twice daily and the addition of her rescue inhaler Proventil which is used
PATIENT ANALYSIS AND TEACHING TOOL 3 no more than twice a week. She reported that her asthma is often triggered around cats and dust, however her most recent exacerbation occurred the previous day due to exertion after running upa few flights of stairs to quickly but was resolved quickly with the use of her emergency inhaler. She describes her asthma presents as “feeling of tightness in her chest and throat, wheezing and difficulty getting enough air”. She reports frequent hospitalizations for asthma when she was younger, with her last hospitalization occurring at the age of 16. She reports use of her peak flowmeter twice a day, in the morning and at night and tracking her readings on a chart.
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- Fall '17