Week 9 passing score 90

Student Documentation

Model Documentation

Vitals

BP 120/82 SPO2 - 99 RR - 15 T - 37.2

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Student Documentation

Model Documentation

Identifying Data & Reliability

Ms. Tina Jones is a 28 years old African American female. Not married and does not have children, currently in relationship with a boyfriend. Presently living with her mother and young sister. Ms. Jones presents to our consult for physical assessment as she newly got hired by a new employer. She is alert, allowing the pertinent data and well articulate. She is able to maintain eye contact, appropriately communicate and engage in the assessment.

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General Survey

Ms. Jones is alert, engaged in her health matters and compliant with the follow ups. Seating in upright posture, articulate, with not stressed appearance , groomed well nourished , appropriately dressed and maintains good hygiene.

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Reason for Visit

" I came because I 'am required to have a recent physical exam for the health insurance at my new job"

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History of Present Illness

Ms. Jones 28 years old African American female that presented for physical examination for the insurance of new job. She states that she does not have any present medical concern. The patient does have history of Diabetes, asthma and High blood pressure. The patient was prescribed with metformin around 5 months ago during her last physical exam, and also was diagnosed with PCOS by ger gynecologist at this time birth control medication was prescribed. Ms Jones reports some side effects associated with metformin , but also stated that those side effects were managed using yogurt. She stated stopping the use of Advil for cramps. MS Jones claims to be feeling currently healthy and looking forward the new employment.

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Medications

Advil for cramps occasionally Metformin 850 mg twice a day Flovent daily inhaler and Proventil as a recue inhaler , she is presently using estradiol as birth control medication.

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Allergies

Not food allergies identified. Allergic to cats and dust , she is also allergic to penicillin that given her rushes.

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Medical History

Ms, Jones was diagnosed with asthma when she was 2 years old, for which presently she use Flovent and Proventil in the morning and evening. She is allergic to cats and dust. She was also diagnosed with diabetes 4 years ago and now treated with metformin she started treatment 5 months ago. She has been regularly checking her blood sugar since and stated currently being in the 90's. She reported that initially she had some side effects from metformin , but she had since manage it . She also has High Blood pressure, which she has been able to manage with exercises and diet. She stated being heterosexual , does not have STDs and has been sexually inactive for while but presently she does have a boyfriend, About 5 months ago Ms. Jones was diagnosed with POCS and estradiol was prescribed. She reported using Advil occasionally for cramps.

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Health Maintenance

Ms. Jones is aware of the importance of dieting and exercise and expressed being engaged in both. She stated being active physically. She stated she does not strain herself and does not have any breathing problems. As per patient she occasionally goes swimming with friend and plays active roles in the church. Ms Jones last physical examination was 5 months ago , her immunization are up to date , she had a tetanus booster about a year ago and her last flu shot was 5 to 6 years ago. She stated taking tetracycline for her acne when she was in high school and her skin has been better since then. MS Jones strives to maintain safety in everything she does and ensure she live a healthy productive life.

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Family History

Ms Jones is overweight. She does have a sister who is 15 years old and has asthma under control , Ms. Jones father died when 2 and half years ago in a car accident he was 58 years old, he had High blood pressure , high cholesterol , and diabetes. Her mother is 50 years old she does have high cholesterol and high blood sugar . Paternal grandfather is 82 also with high cholesterol and high blood pressure, maternal grandfather dies of heart attack at the age of 80 he also had high cholesterol and high blood pressure. The maternal grand mother died of colon cancer when she was 73 and also had the high cholesterol and high blood pressure.

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Social History

Ms Jones has never married, but she currently has a boyfriend and they are to have sex. She lives with her sister and her mother since her father died. She is about to move to her own place.MS jones recently graduated and stated having a good relationship with her family , occasionally goes swimming with friend, goes to church , uses diet coke as source of caffeine , does not smoke cigarettes and drinks alcohol socially no more that 2 drinks. She does not use recreational drugs. She used marijuana in the past it has been 6 years since,

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Mental Health History

Ms. Jones stated not being depressed , currently exicted about her new job, never had suicidal ideations , expressed getting stressed in the past by school.

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Review of Systems - General

High blood glucose about 5 month ago. Has not had fevers, chills or night sweats. recently some weight lost but not willingly. No headaches , no nausea.

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Student Documentation

Model Documentation

Subjective

Reports t have had headaches in the past, specially related to school work, she has not had headache for while , no pain , not itchiness on ayes or ears , sinuses clear , sense of smell intact , hearing intact , she does got glasses for eyesight like 3 months ago, does not have problems with throat, no soreness or dryness reported or seen , no difficultly swallowing or breathing

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Objective

Head normocephalic no traumatic lesion noted, symmetric ears, no drainage , nares pink and moist , eyelids symmetric no swelling . vision 20/20 with glasses, conjunctiva pink ,hearing is intact. PERRLA . Gag reflex intact. Eye lids upper and lower symmetric , pink and moist. Internal bilateral ears pearly gray, JAw with appropriate movement no clicks . No masses on the scalp . No palpable nodes in the neck . No Nodules or goiter palpated in the thyroid. No pain reported in the sinus , no axillary nodes palpable. Intra ocular movement intact. Vision intact

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Student Documentation

Model Documentation

Subjective

Does not have problems breathing, does not report cough or chest pain

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Objective

Her chest is symmetric with even and unlabored respirations present to auscultation bilaterally. resonant percussion throughout . FVC1.78 L, FEV11,54 . Posterior chest wall resonant bilaterally. Thoracic expansion symmetric

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Student Documentation

Model Documentation

Subjective

Does not report any issues with heart or beathing , denies chest pain

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Objective

S1 and S2 noted , no murmurs or gallops . PMI at midclavicular line 5th intercostal , no haves , thrills lifts. Has bilateral carotid without bruit, bilateral peripheral pulses present equally. Capillary refill less that 3 seconds. No lower leg edema bilaterally . Bilateral right and left brachial pulses present +2, lower peripheral pulses present +2, right ankle left carotid +2 no thrill , auscultated no bruit bilaterally , abdominal arteries no bruit

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Student Documentation

Model Documentation

Subjective

Does not report diarrhea or issued with the abdomen , no GERT, no dysuria , no vaginal itching does not feel boated does not experience nausea or vomiting

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Objective

Abdomen is symmetric and protuberant , no scars , masses or lesions. Hair from pubis and the umbilicus is coarse , bowel sounds normoactive present in all quadrants. No organomegaly , CVA or tenderness noted. Liver 1 cm below right costal margin , no palpated kidneys or masses , not palpable spleen . Percussed liver span 7 MCL on percussion. CVA tenderness or right none reported

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Student Documentation

Model Documentation

Subjective

reports no pain in the shoulder, arms , muscle or joint. HAd some back pain some weeks ago when she helped a friend carry heavy items when she was moving , she does not have back pain presently, no swelling

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Objective

Upper and lower extremities all have 5/5 strength no masses or swelling , no noted deformities , full range of motion in all extremities

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Student Documentation

Model Documentation

Subjective

Alert and oriented times 4 , no light headedness or loss of balance reported the coordination is intact , speech is intact

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Objective

Cerebral function intact upon assessment , good memory , graphesthesia intact with appropriate alternating movements bilaterally. DTRs 2 + and equal bilaterally

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Student Documentation

Model Documentation

Subjective

Has acne when was young at high school , it stopped with the use of medication. Zits present usually managed by birth control pills

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Objective

Scattered pustules on the face and facial hair on upper lip. Has acanthosis nigricans on the neck . Nails appropriate no abnormalities noted

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