HR 78-comprehensive Shadow Health

HR 78-comprehensive Shadow Health Vitals Student Documentation Model Documentation Temp 37.2 C HR 78 RR 15 BP 128/82 (97.3) SO2 99% Weight 185 lbs Height 5' 7" BMI: 29 • 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 Documentation Model Documentation Identifying Data & Reliability Tina Jones 29 year old African American female. Reliable source and historian Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a preemployment 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 Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent Student Documentation Model Documentation W/D W/N Female; overweight distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Reason for Visit Physical Exam for pre-employment “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 TJ reports she recetnly obtained employment at an accounting firm. She needs to obtain a preemployment physical prior to starting in 2 weeks. She denies any acute health problems today. She lst visited a healthcare provider a few months ago for a pap smear which results she is not sure of. She was diagnosed with PCOS and started on Yaz birth control. She is now taking Metformin for her Diabetes five months ago and testing her blood sugars daily. She states she feels healthier and excited to move to a new place and start a new job. 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. Student Documentation Model Documentation Medications Metformin 850mg BID for Diabetes Proventil 90mcg/spray 2 puffs PRN for asthma Flovent 88 mcg 2 pffs BID Rescue inhaler Yaz Birth conrol pill OTC: Advil PRN (Pt unable to recall dose) • 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) Allergies Cat, Dust, PCN • 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 PMH: Diabetes and Asthma Lower Back Pain resolved Headaches Resolved GERD Resolved Insomnia Resolved PCOS 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 reading