Week 9: Shadow Health DCE Comprehensive Physical Exam

COMPREHENSIVE PHYSICAL EXAM – WEEK 9 2 Week 9: Shadow Health DCE Comprehensive Physical Exam SUBJECTIVE DATA: Tina Jones, 28 years old, African American female Reason for Visit: Pre-employment physical History of Present Illness (HPI): Tina Jones is a 28-year-old African American female who presents today for a complete head-to-toe pre-employment physical exam. She recently gained employment as an accounting clerk at Smith, Stevens, Stewart, Silver & Company where she begins in two weeks. She denies any acute concerns currently. She has had regular check ups for her medical health including a gynecological visit four months ago where she was diagnosed with PCOS and started on an oral contraceptive drospirenone / ethinyl estradiol. At her dental exam five months ago she denies any current dental problems. Her last eye exam was three months ago where she was given prescription glasses to always wear and will follow up in one year. Her last physical exam was five months ago where she was prescribed metformin for her diabetes, and a daily inhaler for her asthma. Medications: Metformin 850mg tabs daily for diabetes control, drospirenone/ethinyl estradiol 1 pill daily for birth control/PCOS treatment, Flovent daily inhaler 2 puffs twice a day, Albuterol (Proventil) Inhaler: 90mcg per spray, 2-3 sprays PRN for asthma symptoms, Advil 200mg tabs, 3-4 tabs PRN for menstrual cramps Allergies: Penicillin (rash, hives), Cats (sneezing, itchy eyes, asthma symptoms), Dust (sneezing, wheezing, itchy eyes), no reported latex allergy. COMPREHENSIVE PHYSICAL EXAM – WEEK 9 3 Past Medical History (PMH): PCOS – diagnosed four months ago, Type II Diabetes – diagnosed age 24, Asthma – childhood diagnosis age unknown. Past Surgical History (PSH): No past surgical history Sexual/Reproductive History: Heterosexual female, not currently sexually active. Indicates new relationship that started about a month ago, with intention to become sexually active. She is currently on birth control and indicates intention to use protective STI contraceptive when needed. No known history of sexually transmitted infections. No history of pregnancy. Personal/Social History: No past or present tobacco use, reports drinking alcoholic beverages (rum and coke) a “few times” per month with friends, indicating she is “not a huge drinker”, use of alcohol started at age 15. Previously used marijuana but quit 6-7 years ago. Denies current use of marijuana, cocaine, heroin, or other illicit drugs. Patient denies drinking coffee, and caffeine intake is limited to two diet cokes per day. TJ states she checks her blood sugar once a day in the morning, with an average blood glucose of 90. She brushes her teeth twice daily and flosses a couple times per week, does not use sunscreen, and indicates healthy sleeping patterns averaging 9 hours each night feeling well rested in the morning. Patient enjoys going out with friends and recently started a book club where they choose a book to read monthly and then get together to discuss it. She is also an active member of her Baptist church with a strong relationship with God, and enjoys watching science documentaries. She recently obtained her bachelor’s degree in accounting. She has had a recent weight loss attributed to healthier eating and walking for thirty to forty minutes four or five times a week, and swimming at the Y once a week. TJ lives at home with her mother and sister, will be moving to an apartment in the city on COMPREHENSIVE PHYSICAL EXAM – WEEK 9 4 her own in about a month. She owns her own car and denies issues with transportation. Denies financial concerns with her new employer, stating she will have full benefits. Indicates recent dietary changes including reduction in carbohydrate intake, elimination of sweets, increase use of whole grains, vegetables, and low-fat ingredients. A 24-hour intake recount includes: smoothie with frozen bananas, strawberries, and yogurt - chicken breast with broccoli, cauliflower, olive oil, garlic, and brown rice – black beans with brown rice, and roasted butternut squash. Never married, no children. Immunization History: Up to date on all childhood immunizations, last tetanus booster about a year ago, denies seasonal flu vaccine. Significant Family History: Mother: high cholesterol, high blood pressure, obesity, age 50. Father: high blood pressure, high cholesterol, diabetes, deceased at age 58 from MVC. Brother: overweight. Sister: asthma. Uncle: alcoholism. Paternal Grandmother: high blood pressure, cholesterol, age 82. Paternal Grandfather: high blood pressure, diabetes, died from colon cancer. Maternal Grandmother: high blood pressure, cholesterol, deceased at age 73 from stroke. Maternal Grandfather: high blood pressure, cholesterol, died from heart attack. Review of Systems: General: Patient endorses recent weight loss, with vitals trend indicating 6 kg weight loss. Denies fever, fatigue, chills, or night sweats. Denies difficulty sleeping. HEENT: Endorses history of headaches while studying, with none occurring in recent history. Denies visual problems with improvement of vision since COMPREHENSIVE PHYSICAL EXAM – WEEK 9 5 obtaining prescription glasses. Denies issues with hearing, taste, or smell. Denies sore throat, difficulty swallowing, or recent upper respiratory infections. Last visual exam was three months ago. Denies history of eye pain, photophobia, blurry vision, or drainage. Denies general HEENT issues.