Health History
Student Documentation Model Documentation
Identifying Data & Reliability
Able to state name and date of birth that matches EHR records. Oriented x3.
(For the record, I did stop before starti
...
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
Able to state name and date of birth that matches EHR records. Oriented x3.
(For the record, I did stop before starting asking questions. There should be a lapse in time. I was documenting)
Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre- employment 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 a 28 year old obese, African American woman who is clearly able to keep up with her ADLs. Her hair is braided, her clothes are clean, she seems to be able to keep up with hygiene. She does not seem to be in any acute distress.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Reason for Visit
Ms. Jones is here for a head-to-toe exam for insurance purposes for her new job.
“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
No present illness, does not admit to symptoms and states she is "doing well, thanks!"
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.
Medications
Metformin 850 mg BID last taken today Proventil 2 puffs PRN 90 mcg/spray
Flovent 2 puffs 88 mcg/spray BID
• 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
Cats - breathing issues, sneezing, itchy eyes. Treat with leaving, showering, and rescue inhaler.
Penicilin, not severe, per pt - hives/rash. Treat by not taking again.
• 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
T2DM at age 24. Treat with diet, exercise, and metformin
Asthma at 2 1/2. Treat with inhalers and watching for triggers.
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 readings being around
90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual
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