Shadow Health

Comprehensive Assessment | Completed | Shadow Health Student Documentation Model Documentation General Survey Tina Jones is a pleasant 28 year old African American woman who presents for pre-employment physical. She offers information freely and without contradiction. Beach is clear and coherent and maintains eye contact throughout the interview. Patient denies any current pain. 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 "I came in because I'm required to have a recent physical examination for the health insurance at my 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 Denies any pain or present illness. 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 QD, Yaz QD, Inhaler PRN, "never more than twice a week, sometimes not at all" • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yesterday) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago) Allergies Penicillin; rash/ hives. • 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. 2