Identifying Data & Reliability - Ans--Ms. Jones
-28-year-old
-African American
-single
-religious preference
-Education
-Occupation: Smith, Stevens, Stewart, Silver & Company
-Occupational history
-woman
-pr
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Identifying Data & Reliability - Ans--Ms. Jones
-28-year-old
-African American
-single
-religious preference
-Education
-Occupation: Smith, Stevens, Stewart, Silver & Company
-Occupational history
-woman
-presents for a pre- employment physical. -She is the primary source of the history. -offers information freely and without contradiction.
-Mrs. Jones Reliable historian
General Survey - Ans-Alert/oriented
-seated upright
-well-nourished
-well-developed
-dressed appropriately
-good hygiene.
Reason for Visit - Ans-SEE HPI
history of present illness - Ans-HPI: "pre-employment physical" prior to initiating employment."
Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the past"
Medications - Ans-+ Fluticasone propionate 110 mcg 2 puffs BID, Metformin, 850 mg PO BID, Drospirenone, ethinyl estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps)
-using topical antifungals, anti-itch creams, steroid topical ointments, eye/ear/sublingual drops, Benadryl, herbs gingko/garlic/primrose.
Allergies - Ans-+Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes)
-Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies.
Health Maintenance - Ans-+ Pap smear (4 months ago), eye exam (three months ago), dental exam (five months ago), PPD (negative, about 2 years ago), wears seatbelt, uses sunscreen.
-Acupuncture, chiropractic care, changes in behavior/personality/mood, memory problems, difficulty learning.
Medical History - Ans-+ Asthma (diagnosed 24 years old), hypertension (resolved with diet/exercise), PCOS (Diagnosed 4 months ago), received childhood vaccinations, meningococcal vaccine (in college), hospitalized in high school for asthma exac
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