Answer:
Based on the comprehensive assessment, Tina Jones is in generally good health but manages several chronic conditions, including asthma, type 2 diabetes, and PCOS. Her current vital signs and recent health maintenance practices indicate she is effectively managing these conditions.
Assessment and Plan:
- Asthma:
- Continue current medications: Albuterol 90 mcg/spray MDI PRN and Fluticasone Propionate 88 mcg/spray BID.
- Monitor symptoms and use peak flow meter regularly.
- Avoid known triggers, particularly cats.
- Type 2 Diabetes:
- Continue Metformin 850 mg BID.
- Maintain current diet and exercise regimen.
- Regular blood sugar monitoring, aiming to keep levels in the 90s.
- PCOS:
- Continue taking YAZ daily.
- Hypertension:
- Monitor blood pressure regularly.
- Maintain a healthy diet low in sodium and rich in vegetables and lean proteins.
- Continue regular exercise.
- Vision:
- Continue wearing prescription glasses.
- Schedule regular eye exams to monitor vision changes.
- General Health:
- Maintain healthy eating habits and regular physical activity.
- Limit alcohol intake and caffeine consumption.
- Avoid smoking and illicit drug use.
- Continue regular dental and gynecological check-ups.
Recommendations:
- Follow up with primary care physician for routine monitoring and management of chronic conditions.
- Ensure medication adherence and refills are managed promptly.
- Continue health maintenance practices, including a balanced diet and regular exercise.
- Schedule routine health screenings as recommended for overall wellness.
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