Comprehensive Note (Tina Jones) (A GUARANTEED)
Date of encounter: August 1,
Patient Name or initials: Tina Jones
Informant: Ms. Jones is a pleasant, 28-year-old African American single woman who
presents for a pre-
...
Comprehensive Note (Tina Jones) (A GUARANTEED)
Date of encounter: August 1,
Patient Name or initials: Tina Jones
Informant: 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.
Chief Complaint (CC): "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 (HPI): Ms. Jones reports that she recently obtained
employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a preemployment 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.Nurs 550
Allergies: Penicillin: causes a rash. Denies food and latex allergies. Ms. Jones is 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.
Medications:
1. Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning).
2. Metformin, 850 mg PO BID (last use: this morning).
3. Drospirenone and ethinyl estradiol PO QD (last use: this morning).
4. Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago).
5. Acetaminophen 500-1000 mg PO prn (headaches).
6. Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago).
Past History: 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, age11. 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 activity. Tested negative for
HIV/AIDS and STIs four months ago
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