1 / 3100%
Assignment 3; Documentation Notes
Students Name:
Institution:
Course Code:
Instructor’s Name:
Date:
Patient Information:
Initials: T.J. F, Age 28, Race; African American
Subjective Data:
Chief Complaint: Employment Physical Examination
History of Present Illness:
Ms. Jones is a 28-year-old African American woman who is now at the clinic for work. Pt's
answers are acceptable, maintaining eye contact during review
Current Medications:
Yaz PO QD birth control Flovent 110mcg 2 puffs BID Albuterol 90mcg 2 puffs PRN Metformin
850mg PO BID Advil OTC
Allergies:
Asthma, itchy
Past Medical History (PMHx):
Asthma diagnosed at the age of two years, uses daily inhalers and rescue inhalers, last
exacerbation 3 months ago Diabetes- diagnosed at 24 years old. Metformin currently receives no
current side effects with gasiness after inital use, pt takes BS QD, average readings 90. Polycysic
Ovarian syndrome- diet and exercise controlled, diagnosed about 4 months ago, birth controlled,
normal and regular menstrual cycles.
Social History (Soc Hx):
Pt only graduated with a degree in accounting, never married, no children, pt male, pt refuses to
smoke or to use drugs, often alcohol and friends. Pt likes to read, lives with her mother and sister
now, but expects to leave next month.
Family History (Fam Hx):
Mother 50- high cholesterol and HTN Brother, deceased at 58 years, high cholesterol, diabetes
and HTN Mother's maternal, disgusting at 73 years, had HTN and high cholesterol Maternal
grandparent, who died at 80 days, had HTN and cholesterol. High cholesterol, Paternal
grandma's 82, HTN Deceased at the age of 60.
Review of System (ROS):
GENERAL: No fatigue or chills
HEENT: No headaches, eye pain, dizziness or blurry vision. No mouth or teeth pain. No sinus
pressure, sneezing, runny nose, change in smell. Pt wears prescription glasses.
SKIN: No rashes.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No reported shortness of breath.
GASTROINTESTINAL: No abdominal pain
GENITOURINARY: No burning when urinating.
NEUROLOGICAL: No numbness or tingling
MUSCULOSKELETAL: No reported stiffness in joints or muscles
HEMATOLOGIC: No bleeding.
LYMPHATICS: no enlarged lymph nodes.
PSYCHIATRIC: No depression
Students also viewed