COMPREHENSIVE HISTORY AND PHYSICAL EXAM WRITE UP (1)

Comprehensive History & Physical Exam Write Up, Pt. 2 Health History Ms. Tina Jones is a 28-year old African American woman who presents for a preemployment physical. She is the primary source of history. She is alert and oriented to self, time, place and situation. Her mood is pleasant. Her language is fluent and speech is clear. She maintains eye contact throughout the interview. She is seated in an upright position on the examination table. She is neatly dressed, has good hygiene and appears well-nourished. She is not in any distress. Ms. Jones states that her last health exam was four months ago, when she received a gynecological exam. She was diagnosed with polycystic ovarian syndrome and prescribed oral contraceptives at that visit. She takes Yaz oral contraceptives by mouth once a day and is tolerating it well. She reports that her menstrual cycles are regular with moderate bleeding lasting five days since taking Yaz. During her gynecological visit, she had a pap smear and tested negative for STI’s and HIV. She states that she is involved in a new heterogeneous relationship and plans to use condoms with sexual activity