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earthstellar · 2 years

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I really love this panel, because not only does it give us our first real taste of First Aid taking command as a lead medic on scene, but there’s a lot we can read into it

that’s right y’all, brace for another long post lmao

First Aid: A Glimpse Into the Future

it’s interesting how Ratchet is posed so far in the background, literally in darker/more severe lighting and hunched over a bit, while both younger medics are far more prominent

obviously there needs to be a layout to accommodate the text bubbles and the focus needs to be on First Aid so he’s naturally going to be the one taking up the most space in the composition here,

but the almost excessive amount of space dedicated to him helps to emphasise a sense of how very much in charge he is in this moment

even the pointing pose (make your Ace Attorney jokes now lol) serves the purpose of further highlighting that First Aid is giving the commands here, which I’ll get into in the next section when I get into the dialogue stuff because that’s super interesting to me because I’m The Healthcare Guy lol

but also!

they are all sized within the panel in “order of importance”:

First Aid not only has the most to say here, so of course he’s going to take up the most space, but compare his confident pose and level of focus/energy here with the lax posture of Ambulon (who is straight up confused lol) and is second in relative size

then compare them both to Ratchet in the background, who is in even heavier shadow (which helpfully emphasises the creases in the face plating under his optics, clearly equivalent to under-eye skin sagging in older humans) and helps to “Ratchet’s old and on his way out”

he’s going into the background here both visually and in terms of his professional position; he’s in the process of handing over the CMO role to First Aid, and we see First Aid literally step up and into the foreground with a lot of forward movement

both First Aid and Ratchet are slightly leaning forward, but with Ratchet it carries a certain weight that it doesn’t with First Aid; we get a sense of immediacy, energy, and confident strength from First Aid-- He knows what he’s doing, which is hammered home in comparison to Ambulon’s confusion

the fire in the corner of the panel is interesting; not only does it help with the dramatic lighting (which helps to age Ratchet a bit more visually with the heavier shadow back there), but we associate fire with danger, being on high alert, being at risk or dealing with a serious threat

in relation to the fire, First Aid appears to be entering it or already in contact with it (again, the sense of forward movement or action), while Ratchet is behind it (his time in the lead is over and he’s in more of a support role here), and Ambulon is on the other side of it completely (unaware of the threat, hence confusion)

it’s a really great panel, which achieves a lot all in one go!

but the dialogue, oh hell yeah, firing up my size S nitrile hypoallergenic gloves so I can start typing with my Chronic Healthcare Guy Brain fully engaged lmao

SBAR in Cybertronian Medicine: Confusion is Bad

now, welcome to a basic rundown of SBAR and why I am talking about this shit in the context of space robot medics

going to massively summarise this because it is a whole Thing

but essentially, SBAR is a communication assessment tool designed to help facilitate high speed and highly accurate sharing of information!

SBAR stands for Situation, Background, Assessment, and Recommendation.

Now, SBAR is used in healthcare pretty often! Usually during handovers, but I’m just using this as one example of a comms tool in healthcare environments purely because it’s one of the easier ones to go over.

Here are a couple key NHS documents for examples of how SBAR can be implemented and used in healthcare communications:

NHS Safer Care - SBAR Implementation and Training Guide

NHS SBAR Communication Tool Document

There’s also a pretty good write-up available here, too.

and here’s an example of some NHS Health Trust documentation which includes some SBAR notes and procedure in regards to deteriorating patient policy. it might provide some insight into how these things are considered, assessed, and implemented!

why this is relevant: First Aid is good, but he’s still learning, and seconds count when the situation is escalating

we see in the above panel that shit is getting real, and the medics need to come in.

and the medics are here-- which is good!

but what the hell is going on?

while I’ve used SBAR as an example of a communication framework often used to help ensure clarity in certain healthcare / medical contexts, it’s certainly not the only comms framework that can be utilised.

for the situation in the panel above, what are some key questions which come to mind? what information needs to be disseminated most immediately? what do we need to take into consideration right away?

does every medic present have an idea of what is happening, or is there a discrepancy in regards to who’s aware of what?

is knowledge of the situation being disseminated effectively?

how is the situation being communicated between medics?

how is the situation being assessed?

how are they approaching the situation as a medical team?

First Aid does step up and immediately-- But all he does is tell Ambulon to get to the second aisle.

Ambulon is clearly unaware of the immediate situation, and First Aid’s initial instruction does not include the relevant information: Okay, go there, but to do what, and why? Who’s involved, what’s going on, what needs to be done?

To his credit, First Aid immediately responds once he becomes aware of Ambulon’s confusion with a lot of good and important information:

who is involved (who needs attention, who are the most immediately in need of care)

the condition of the patients

guidance on how to provide effective care / immediate treatment quickly

instructions on what to expect and how to manage the patients following immediate interventions

addresses Ratchet by identifying the not-as-immediately-in-need patients, clearly informing him of who to address and what needs to be done

But ideally, he would have started by providing these details as needed, rather than simply pointing and directing Ambulon over there somewhere.

Fair enough, this could just be First Aid getting excited and jumping into it and needing a second to really get into the role as a leading responder; we know that First Aid does tend to be a little more emotionally engaged/excitable

and while those traits can be good, it might also mean that he may need a little more experience in a lead position before he really gets used to remembering that he’ll need to take that time to communicate information more effectively right at the beginning

but at the same time, of course canonically we don’t know a whole lot about Cybertronian medical systems or training, or how medics might be trained to communicate.

Cybertronians, Communications, and Clarity: Why Use Lot Word When Instant Message To Brain Module Do Trick?

we don’t know, for example, if they may be able to communicate more rapidly or effectively via data packets or some other Cybertronian information sharing method that might be naturally more quick and more organised than sharing information verbally at all

we also don’t know if any such communication method may have a certain benefit/risk ratio that may limit its use when addressing active incidents or when carrying out medical care on scene etc.

but it is interesting to think about!

communication frameworks are not one-size-fits-all; different situations call for appropriate variations or different comms models entirely

it may well be the case that in Med Bay environments, an SBAR type framework for communication might be used when appropriate-- like I said, this particular comms structure is commonly used to facilitate solid handovers, or in situations where a patient’s condition needs to be communicated to another clinician/etc. who may not be familiar with this particular case beforehand.

SBAR is a good system, because it effectively summarises a lot of key information in an easily organised and clear manner; the goal is to ensure that a lot of details are shared in a well structured way to help maintain clarity.

(There is a slight variation of this called SBARD, and you can find an example worksheet for this here. D stands for Decision in this version of the comms tool. but I won’t get into too many variations, just want to include this so that y’all know that there are some variations out there and their application will vary!)

but there are lots and lots of different systems and approaches for communicating between medical staff in various different scenarios or situations, and there’s no universal model that can be applied all the time.

what is most effective, will depend on a lot of different factors, and can often be subject to change as a situation evolves.

with Cybertronians, given their inherent potential for multiple different modes of communication, it would be very interesting to see a comms protocols document for Med Bay staff, field medics, etc. and what the differences are...

but something like SBAR, I can see that being used in pretty much the same way it gets used in a lot of healthcare environments in real life. it’s simple, it’s effective, and it makes documentation much easier and encourage better records accuracy

because I can 100% see this being an issue on the Lost Light LMAOOOO

I’m sure Ratchet would insist on the use of something similar to this, if only because “Whirl punched in helm -- reset optic lens, OK to discharge! :)” is not sufficient medical documentation, lol

also, Velocity is Camien; it may be the case that medical records may be completed in a slightly different way / according to slightly different best practice protocols owing to any differences between Camien and Cybertronian healthcare systems

plus, I’m sure the war ended up influencing how Cybertronian medical systems and records are maintained and completed... ANYWAY

an example of SBAR in the Lost Light Med Bay might look something like this:

Scenario: Velocity is about to go off duty, the patient (Swerve) is still in the Med Bay, thus a handover to Ratchet is needed.

S = Situation

Patient Name: Swerve [+ other details like serial number, age, etc.]

Presenting Complaint: Arrived to Med Bay at [time/date] presenting with severe fuel tank ache, some fuel reflux, severe helm ache, mild nausea.

Patient indicated fuel tank ache and helm ache as 7 out of 10 on Pain Scale at time of admission to Med Bay.

[Note key vitals and other critical basic details as part of any standard info; Spark rate/stability, thermal readouts, etc.]

B = Background

History of Presenting Complaint: Patient states fuel tank ache began around [time] following consumption of “some horrible trash garbage Whirl made”, then gradually escalated to severe helm ache with nausea over the course of [timeframe].

Medical History Summary: Prior history of Depression, Generalised Anxiety. No known other conditions. Last general check-up attended on [date/time], no concerns present at that time. Slightly above average engex consumption owing to occupation as bar staff.

Drug History / Allergies: No known allergies. No prior drug history.

A = Assessment

Clinical Observations: Vital signs stable, slightly elevated self-repair nanite concentration in internal energon sample and elevated thermal readouts indicative of contaminated fuel consumption.

Fuel tank sample toxicology report indicated presence of an engex derivative compound, chemically similar to Betelgeux whiskey. Negligible amount of Gurunium was also detected in sample. [Relevant numbers/values/info from toxicology report here.]

Patient observed to be ambulatory and otherwise stable. Patient mood generally positive, talkative and responsive to engagement from others. No further symptoms or concerns have developed as of [time/date].

Second Pain Scale assessment carried out at [time/date], patient reports decreased pain level of 3 out of 10 following treatment administered as noted below.

Patient continues to report persistent fuel tank ache; Helm ache and nausea have ceased.

Treatment Given: Orally administered [name of medication(s), dosages] at [time/date]. Primary fuel line and secondary fuel line flushed with medical grade energon. Patient admitted for short term observation owing to abnormal toxicology panel and self-reported persistent fuel tank pain.

R = Recommendation

Monitor for any recurrence / change in symptoms or development of any new symptoms for [suggested time period]. Administer second dosage of medications [list medication information again] at [time/date] and carry out third Pain Scale assessment.

Carry out second fuel tank sample for further toxicological analysis, compare to initial toxicology report to evaluate effectivity of fuel line flush. If no concerns / symptoms resolve, patient may be assessed for discharge.

Now, that’s a bit wordy, but I’m going to justify it by saying these are space robots and they probably have more efficient ways to process data like medical records, so maybe glyphs are more effective than human written language systems to some degree etc.

The above SBAR example helps ensure that Ratchet gets all the basic information he needs to pick up with Swerve’s care where Velocity will be leaving off shortly.

back to the reason for this post lmao: First Aid is babby CMO, confusion on scene is bad but he did good correcting that and with taking charge overall, solid 8/10

it is interesting to think about how bots might deal with potentially critical communication issues like this, especially in a medical /healthcare context.

it’s entirely possible that even though Cybertronians are capable of various different types of communication, it may be uncomfortable, distracting, rendered impossible (via comms disruptors etc.), or otherwise less than ideal for care teams that are on field duty or in other non-Med Bay environments, or one method that works under fire isn’t as effective or appropriate to use in a Med Bay, and so on.

which would be similar to real life, where lots of different comms frameworks exist, not just SBAR, to help ensure the most relevant information is provided in the most effective way within the context of whatever’s going on.

we don’t have a lot of canonical details on how Cybertronian medical systems work etc. so I can’t say for certain!

but I think this was a great way to depict First Aid taking on more team lead duties.

he’s stepping up gradually into the CMO role, and we get that wonderful framing and all the nice little visual details here to help highlight that.

and with the dialogue, even though there’s a bit of a rough patch there with med team communications at the start, it’s in character for First Aid to want to hit the ground running. he’s a great contrast to Ratchet

and Ambulon is a good balance in this scene, who helps underline that First Aid is on top of the situation, there are just a few little things to get a little better at, and they will over time with some more experience both individually and with working as a team in their new roles.

and I appreciate that realistic approach a lot; nobody enters a new role and immediately gets everything 100% right. First Aid isn’t magically as competent as Ratchet; his approach to taking charge is higher energy, there’s a little bit of a comms fumble there at the start, his vibe in the lead role on scene is different, and that’s real

it helps highlight his inexperience (compared to Ratchet) while also immediately emphasising that he DOES very much know what he’s doing and can take charge, he’s just new and getting used to directing his team on scene

he’s confident and excited to prove himself and you know, he did a pretty good job. it’s a really solid 8/10, which is great considering this is one of the first times we see First Aid on panel actually taking charge directly.

of course, he has prior experience pre-Lost Light, but the difference is that now, he knows he’s inheriting the role of CMO from Ratchet, who is a living medical legend.

Reality Hurts: Ratchet can’t be CMO forever

it’s a high bar, but First Aid generally is a very confident person. for the most part, he has a lot of faith in his knowledge and skills, he’s not afraid to innovate on the fly when needed, he’s willing and able to speak up for himself and his patients.

you can absolutely see why Ratchet views him as a good successor; he doesn’t always agree with First Aid, and handing over his position is extremely emotionally and professionally difficult for Ratchet-- and we see a few times where that comes into play, when First Aid has called him out a bit on how he’s still holding onto the title long after he announced his plans to retire

which Ratchet likes. not a lot of people argue back. but First Aid does, and it’s likely that Ratchet appreciates that, even when it stings. because if First Aid is willing to shout back at him, that instils a lot of confidence that First Aid will speak up to anyone for what he thinks is right, to advocate for a patient, to not take any shit from anyone.

yeah, anyone entering a new role is gonna goof it a little, but we see so much confidence and expertise from First Aid here, and we see Ratchet off in the background, listening and taking orders from his chosen successor

there’s a shift here, where we see this move towards change actually sort of start to materialise.

Ratchet Stepping Down, First Aid Stepping Up

First Aid is maturing more and more into the role he knows he’s going to get, and Ratchet sees what he’s doing and is still present, but he’s not leading here.

he’s hands-off, for the most part, and we know how hard that is for Ratchet. he’s making an effort here which is emotionally hard for him to cope with; while he is proud of First Aid and truly sees the potential in him to be a great CMO, inevitably, it hurts.

Ratchet doesn’t want to retire. But he knows there’s something wrong with him, he can’t fix it, it’s not getting better, and if nothing else, his medical inability to carry out his job would place patients at risk past a certain point.

And he’s not willing to risk that. By Cybertronian standards, it is essentially early retirement; While Ratchet is old, he’s not actually all that much older in terms of years from moment of sparking/being forged. Drift is of a similar age range.

And Ratchet really struggles with knowing that, yeah, he’s on the way out. He doesn’t want to be, but he is, and he needs to be, and it hurts because he has very much made his job integral to his sense of self-identity and self-worth. He is afraid of being “defunct”, of no longer being able to serve his purpose; I often wonder if Ratchet just unavoidably internalised some of the harmful Functionist ideas from the past and can’t shake it.

But he knows his time is up, and he knows it’s just the way it is, and he knows that First Aid should arguably have been briefed and promoted to CMO already, and he knows that this is inevitable.

We see a sort of silent change in this panel; It’s the first time we get a very obvious sense that okay, Ratchet’s literally going into the background here. First Aid is now really getting ready to be the CMO, Ratchet is in the process of acceptance, and they’re both actually doing a pretty solid job here.

First Aid is on the come up, Ratchet is on the way out, and in this panel, there’s this great vibe that this is how it’s going to go down, this is the real actual start of that process, and you know what, it’s OK.

any change is a process. it’s frustrating, it’s hard, it’s sad, it’s exciting.

and it’s done so well, it’s handled very realistically, what it’s like from both sides:

being the older person knowing it’s time to pass things down to the next generation yet still struggling to do so, not knowing what to do “after” and not wanting to face the reality of being past the most significant era of your life, having to step away from what defined you to yourself, handing over what you loved-- what you still love--with the awareness that you will not be able to go back; not in the same way, at least. it isn’t over, but it is ending. it’s inevitable, you know that. but it’s still hard.

and being the younger person who is dealing with a lot of difficult circumstances but at the same time holding the competency and motivation to prove your worth and step up as needed, the energy and the drive and the knowledge is there, the experience will come with time once you get the chance to actually get that experience, and there’s frustration and fear and stress and a sense of pride, a sense of satisfaction when you get to take control, there’s the desire to do this right and it’s a lot, there are big shoes to fill, there’s pressure-- but there’s a hell of a lot of potential, too. with youth, comes hope.

in closing: I am able to overthink myself into crying over any and every scene in this entire series, and I consider this to be my superpower

I like this panel, because it’s low key all about change and growth and personal development.

it’s subtle, but inevitable, and sometimes it gets to a point where shit gets real and you gotta rip that bandage off and just let progress happen.

First Aid will make a good CMO.

Ratchet is gradually facing the decline of his health and impending retirement with incrementally more and more acceptance.

And so, time moves on.

At first, with some difficulty.

But eventually, with grace.

---

aaaaand I’m done! PHEW.

if you read this, you’re amazing and I love you <3

I’m sorry I write forever and never edit these all that much LMAO, truly, you have all earned a Rodimus Star <3

also once again, I am asking whoever owns the comic rights at this point to please let me be a script consultant for any med bay shenanigans, not even joking who do I email about this lmao

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mynursingessaypapers · 1 year

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SHADOW HEALTH ASSIGNMENT HELP!

NRS 434 Shadow Health: Comprehensive Assessment

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT NRS 434 Shadow Health: Comprehensive Assessment

Complete the Comprehensive Assessment on the Shadow Health platform. This homework should take 3 hours on average each time to finish. Please be aware that this is a typical time. Some pupils might require more time.

This clinical encounter serves as a thorough examination. The Shadow Health Digital Clinical Experience requires students to get a “Proficiency” score. There are three chances for students to finish this assignment and receive a Proficiency level grade. Once finished, drop the lab pass into the assignment dropbox.

Students who successfully complete the Digital Clinical Experience at the Proficiency level on their first attempt will receive a grade of 150 points; students who complete the Digital Clinical Experience at the Proficiency level on their second attempt will receive a grade of 135 points; and students who complete the Digital Clinical Experience at the Proficiency level on their third attempt will receive a grade of 120 points. If students do not pass the performance-based assessment after three attempts by scoring at the proficiency level, they will receive a failing grade (102 points).

If Proficiency is not achieved on the first attempt, it is recommended that you review your responses with the correct answers on the Experience Overview page. Click on each of the tabs to the left labeled Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work with the report. You could improve your grade by reviewing this summary and the course materials.

Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to Lopes Write.

If Proficiency is not achieved on the first attempt it is recommended that you review your answers with the correct answers on the Experience Overview page. Review the report by clicking on each tab to the left titled; Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. Reviewing this overview and course resources may help you improve your score.

Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to LopesWrite.

Also Read: Assignment: Research Critiques and PICOT Statement Final Draft

Attachments

NRS-434VN-R-CLC-HealthPromotionPres

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT NRS 434 Shadow Health: Comprehensive Assessment

Describe the characteristics of the aging process. Explain how some of the characteristics may lead to elder abuse (memory issues, vulnerability, etc.). Discuss the types of consideration a nurse must be mindful of while performing a health assessment on a geriatric patient as compared to a middle-aged adult.

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Replies to Thomas Leen

Aging is an inevitable process in our lifecycle. Older adults are looked to for guidance and wisdom from those younger and far less wise than they are. When the mind or body starts to deteriorate younger generations tend to seek that guidance less and less. Some individuals tend to take in his or her parents when they get to the point where the body or mind start to diminish. After a time, these family members that take in the older aging adult can begin feeling the frustration of caring for someone else and not having them be the same person the family member remembers from younger years. Some examples of this frustration can be expressed through negative outlets such as verbal abuse, physical trauma inflicted, or lack of attention needed for daily living (bathing, eating, toileting, moving).

The population of older adults 65+ has steadily increased over recent years. According to Federal Interagency Forum on Aging-Related Statistics, “The prediction is that older adults comprise 21% of the population by 2030” (2016). The aging process will likely bring about other chronic health conditions in that time.

According to Green, “frailty includes the presence of biomedical factors that reduce the older adult’s ability to endure environmental stressors, such as hospitalization” (2018). Alarming numbers are reported by The World Health Organization in regards to elder-abuse or neglect; an estimated 1 out of 6 older adults fall victim. This is saddening because often times the abuser/ person neglecting is a close family member caring for the older adult. Memory loss and decrease physical abilities (different from findings of middle age adults) are a few reasons these older adults fall victim to the hands of caregivers, but identification of the fear and injuries is vital to ensure a safe and caring environment.

Nurses must utilize thorough assessment skills in order to identify signs and symptoms of elder abuse. Scattered bruising around the body that appear different colors. This indicates that the bruises are from different time periods. Elder abuse can also come in the form of malnourishment, pressure injuries, or the far less visible emotional/ verbal abuse.

Though emotional and verbal abuse are less noticeable, asking many questions and just listening to the patient will que in certain details that nurses can likely pick up on to further evaluate the safety of his or her environment. Understanding that the older adult will likely not address any mistreatment. Patients and family members alike trust nurses and the care they provide; using that relationship and asking more personal detailed questions about findings is important to keep the patient(s) safe.

References:

Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans 2016: Key Indicators of

Well-Being. Retrieved from https://agingstats.gov/docs/LatestReport/Older-Americans-2016-

Key-Indicators-of-WellBeing.pdf

Green, S. Z. (2018). Health assessment of the aging adult. In Grand Canyon University (Eds.), Health

assessment: Foundations for effective practice. https://lc.gcumedia.com/nrs434vn/health-

assessment-foundations-for-effective-practice/v1.1/#/chapter/5

World Health Organization. (2018). Elder abuse. Retrieved from http://www.who.int/en/news-

room/fact-sheets/detail/elder-abuse

Documentation / Electronic Health Record

Documentation

Vitals

Student DocumentationModel Documentation

Vitals

Heght 170m cm, weight: 84 BMI: 29.0 blood:NA, Glucose: 90. RR: 15, HR: 78, BP: 128/82, Pulse Ox: 99%, Temperature: 99.0 F

• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F

Health History

Student DocumentationModel Documentation

Identifying Data & Reliability

The patient is a 28-year old singkle African-American woman who comes to the clinic for physical assessment. She gives the information and is cooperative. Her speech is clear and she maintains eye contact during the process.

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.

General Survey

The patient is alerrt and oriented. He sitting position is upright. She is of good health and appropriately hygienic.

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

“I need to have a health insurance for my new job”

“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

The patient states that she is newly employed at her company. She lacks any concern that may be described as acute. She last underwnt a gynecological exam at the SHGC 120 days ago. Tina was diagnosed with POCS and prescribe well tolerated medications. The patoent suffers from type 2 diabetes that she has been controlijng using metforming, diet and exercise. The drugs do not produce any side effects.

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.

Medications

Metformin 850 mg po BID Drospitenone and ethinyl estradiol PO QD Albuterol spray that she puffs twice and last use occured 3 months ago. Acetaminophen 500-1000 mg PO prn for headaches. Ibuprofen for menstrual cramps ans last taken 6 weeks ago.

• Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yesterday) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)

Allergies

Allergic to penicillin, cats and dust. She is not allergic to food and latex.

• 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

The patient was diagnsoed with asthma at 2 and a half years old. Last asthma exacerbation occured 3 months ago. Never been intubated. Suffers from tyoe 2 diabetes. Uses metforming to manage the condition. Average blood sugar is 90 and the patient monitors it daily. She also uses exercise and diet to manage her sugars. Negative for any history of surgery. OB/GYN: She developed menarche at the age of 11. She has sex with men. She has never been pregnant whilst she had her first sex at the age of 18. Has a new boyfriend.

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she experiences exacerbations, such as around dust or cats. Her last asthma exacerbation was yesterday, 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.

Health Maintenance

The patient attends to the doctor’s appointment. Had a pap smear 4 months ago. Had an eye exam 3 months ago. The dental exam was last conducted 150 days ago. She is negative for PPD that was done two years ago. Her immunization status is current bar tetanus and HPV vaccines. Childhood vaccines are up to date ad as well as meningococcal vaccine. Safety: Has smoke detectors in the home. wears safety belts in the car. Does not ride the bike. Uses sunscreen in the sun. she has locked her father’s gun in their bedroom.

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 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

High blood pressure in all the grandparents from both parents. Both parents and maternal grandparents have high cholesterol. Stroke killed maternal grandparents. Paternal grandmother is alive and 82 years of age whilst fgrandfather died of cancer at 65. The latter also had a history of type 2 diabetes alongside the patient’s father who died in an accident. Has an overweight brother and an asthmatic sister. Alcoholism in paternal uncle whilst no other diseases exist in the family as well as her.

• 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

The patient does not have children and they were never married. Lives with the mother alongside sister in a single apartment but planning to move to her own once she starts work. She enjoys reading, attending Bible studies, dancing and attending church functions. Has a string social support system including the church and her family. Doesn’t do tobacco whilst she used cannabis from ages 15-21. Does not abuse any other drugs. Uses alcohol in the company of friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, lunch to supper. Does not take coffee yet takes diet coke. Has not travelled outside recently and does not keep pets. Does mild exercise at least four times per week.

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.

Mental Health History

Has enhanced coping mechanism to stress. Does not suffer depression, anxiety, or suicidal thoughts. She is alert to all faculties. She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear.

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.

Review of Systems – General

(No Documentation Made)

No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase.

HEENT

Student DocumentationModel Documentation

Subjective

Does not report current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visitto the optometrist was 3 months ago. Reports no problems in the heart, change of hearing, ear pain, or discharge. Report no change in sense of smell, sneezing, epistaxis, sinus pain, or pressure. or rhinorrhea. Reports no general mouth issues. Dental concerns nonexistent. Swallowing, is okay, no sore throat, voice changes or swollen nodes.

Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.

Objective

Normocephalic head, and atraumatic as well. Bilateral eyes with equal hair distribution on lashes and eye brows, lids without lesions. No ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. OEMS intact bilaterally, no nystagmus. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMS intact and pearly gray bilaterally, positive light reflex. Whispered wors bilaterally head. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions. Uvula rises midline on phonation. Gag reflex is intact, Dentation minus evidence of carries or infection. Tonsils 2+bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.

Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Respiratory

Student DocumentationModel Documentation

Subjective

Reports normal breath, lack of wheezing, chest pain, dyspnea and cough.

Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.

Objective

Chest is symmetric. The lung sounds are clear whilst voice occurs in all areas. Percussion produced resonance throughout. In office spirometry: FVC 3.91, FEV1/FVC ratio 80.56%

Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Cardiovascular

Student DocumentationModel Documentation

Subjective

Reports no palpations, tachycardia, easy bruising or edema.

Reports no palpitations, tachycardia, easy bruising, or edema.

Objective

Hear rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral crotides equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts or thrills. Bilateral peripheral pulses equal bilaterally, capillary refills less than 3 seconds. No peripheral edema.

Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves or lifts. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

Abdominal

Student DocumentationModel Documentation

Subjective

Reports no nausea, vomiting, pain constipation, excessive flatulence or diarrhea. Does not have food intolerance. Genitourinary: Does not have dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.

Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.

Objective

Abdomen is protuberant, symmetric without visible masses, scars, or lesions, coarse hair from pubis to ambilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegally. No CVA tenderness.

Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Musculoskeletal

Student DocumentationModel Documentation

Subjective

Does not have muscle and joint pains whilst muscle weaknesses and swelling don’t exist.

Reports no muscle pain, joint pain, muscle weakness, or swelling.

Objective

Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.

Bilateral upper and lower extremities without swelling, masses, or deformity and with full range of motion. No pain with movement.

Neurological

Student DocumentationModel Documentation

Subjective

Does not have dizziness, tingling, light-headedness, seizures, loss of coordination or sensation, sense of disequilibrium.

Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.

Objective

Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterally. Cerebella function tests produced normal results. DTRs 2+ and equal bilaterally in upper and lower exremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Strength 5/5 bilateral upper and lower extremities. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin, Hair & Nails

Student DocumentationModel Documentation

Subjective

Reports that the oral contraceptives have led to improved acne. Skin has stopped darkening at the neck region and facial and body hair has improved. She reports few moles but no other hair or nail changes.

Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.

Objective

Pustules on the face are scattered whilst the upper lip ha facial hair. The posterior neck has acanthosis nigricans. Nails are free of ridges or abnormalities.

Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck.

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