Documentation / Electronic Health Record
Documentation
Vitals
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BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Height
5'6" BMI 29 BS 100
• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose:
100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% •
Temperature: 99.0 F
Health History
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Identifying Data & Reliability
Ms. Jones is a pleasant 28 year old African American female who
presents to the clinic today for a physical for employment. Pt's
responses are appropriate, maintains eye contact throughout exam.
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
Pt in no apparent distress, alert and oriented x 4, calm and
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.
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cooperative, appropriately dressed wtih good hygiene.
Reason for Visit
Pt states she needs an employment physical for a new job she will
be beginning in two weeks.
“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
Pt presents to the clininc for an employment physical that she will
begin in two weeks. Pt denies any medical issues or concerns.
Since last visit pt has had her annual PAP smear resulting diagnosis
of PCOS with treatment using birth control, had her annual eye
exam resulting in prescription glasses, pt states her diabetes is now
controlled with medication and exercise. Pt. states she is eating
healthier and has reduced her soda intake. Pt's perception of health
and self is good.
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
Flovent 110mcg 2 puffs BID Albuterol 90mcg 2 puffs PRN
Metformin 850mg PO BID Advil OTC regular strength PRN for
cramps Yaz PO QD birth control
• 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)
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Allergies
PCN- skin rash Cats- exacerbates asthma Dust-exacerbates asthma,
itchy
• 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
Asthma- diagnosed at 2 years old, uses daily and rescue inhaler,
last exacerbation 3 months ago Diabetes- diagnosed at 24 years
old, currently takes Metformin with gasiness upon inital use wtih
no current side effects, pt taking BS QD, readings on average 90.
HTN- controlled with diet and exercise Polycysic Ovarian
Syndrome- diagnosed approximately 4 months ago, controlled with
birth control, menstrual cycles normal and regular.
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 activity. Tested
negative for HIV/AIDS and STIs four months ago.
Health Maintenance
Since last encounter at teh clinic pt has had an OBGYN exam
approximately 4 months ago, pt had had an eye exam
approximately 3 months ago. Pt states she is now exercising
regularly, has been eating healthier, and has cut back on her
Last Pap smear 4 months ago. Last eye exam three months ago.
Last dental exam five months ago. PPD (negative) ~2 years ago.
Immunizations: Tetanus booster was received within the past year,
influenza is not current, and human papillomavirus has not been
received. She reports that she believes she is up to date on
childhood vaccines and received the meningococcal vaccine for
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caffiene and soda intake.
college. Safety: Has smoke detectors in the home, wears seatbelt in
car, and does not ride a bike. Uses sunscreen. Guns, having
belonged to her dad, are in the home, locked in parent’s room.
Family History
Mother 50- high cholesterol and HTN Father- deceased at 58, high
cholesterol, diabetes, and HTN Maternal grandmother- deeased at
73 from stroke, had HTN and high cholesterol Maternal
grandfather- deceased at 80 from heart attack, had HTN and
cholesterol Paternal grandmother 82- high cholesterol, HTN
Paternal grandfather- deceased from colon cancer mid sixties, had
high cholesterol, diabetes, and HTN Sister 15- Asthma Brother 26-
obese Paternal uncle- alcholism Denies any other family medical
history.
• Mother: age 50, hypertension, elevated cholesterol • Father:
deceased in car accident one year ago at age 58, hypertension, high
cholesterol, and type 2 diabetes • Brother (Michael, 25):
overweight • Sister (Britney, 14): asthma • Maternal grandmother:
died at age 73 of a stroke, history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a stroke, history of
hypertension, high cholesterol • Paternal grandmother: still living,
age 82, hypertension • Paternal grandfather: died at age 65 of colon
cancer, history of type 2 diabetes • Paternal uncle: alcoholism •
Negative for mental illness, other cancers, sudden death, kidney
disease, sickle cell anemia, thyroid problems
Social History
Pt just graduated college with an accounting degree, never married,
no children, pt in a relationship with a male, pt denies smoking or
drug use, occasional alcohol with friends. Pt likes to read, currently
lives at home with her mother and sister but has plans to move out
next month.
Never married, no children. Lived independently since age 19,
currently lives with mother and sister in a single family home, but
will move into own apartment in one month. Will begin her new
position in two weeks at Smith, Stevens, Stewart, Silver, &
Company. She enjoys spending time with friends, reading,
attending Bible study, volunteering in her church, and dancing.
Tina is active in her church and describes a strong family and
social support system. She states that family and church help her
cope with stress. No tobacco. Cannabis use from age 15 to age 21.
Reports no use of cocaine, methamphetamines, and heroin. Uses
alcohol when “out with friends, 2-3 times per month,” reports
drinking no more than 3 drinks per episode. Typical breakfast is
frozen fruit smoothie with unsweetened yogurt, lunch is vegetables
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with brown rice or sandwich on wheat bread or low-fat pita, dinner
is roasted vegetables and a protein, snack is carrot sticks or an
apple. Denies coffee intake, but does consume 1-2 diet sodas per
day. No recent foreign travel. No pets. Participates in mild to
moderate exercise four to five times per week consisting of
walking, yoga, or swimming.
Mental Health History
Pt denies any mental health history. Pt states stress has decerased
and she is feeling better these days. Pt does report some issues
sleeping and some depression after her father passed.
Reports decreased stress and improved coping abilities have
improved previous sleep difficulties. Denies current feelings of
depression, anxiety, or thoughts of suicide. Alert and oriented to
person, place, and time. Well-groomed, easily engages in
conversation and is cooperative. Mood is pleasant. No tics or facial
fasciculation. Speech is fluent, words are clear.
Review of Systems - General
General: no weakness, fatigue or fevers. Positive weight loss of 10
pounds. Skin: no rashes, lesions, dry skin, ithcing or clor changes,
no dandruff, or changes in nails. HEENT: No headaches, eye pain,
dizziness or blurry vision. No ear pain or drainage. No mouth or
teeth pain. No sinus pressure, sneezing, runny nose, change in
smell. Pt does wear prescription glasses. Cardiac: No chest pain,
palpitaitons, or edema. Pt has history of HTN, now controlled.
Respiratory: No SOB, difficulty breathing, or wheezing. Pt has a
diagnosis of asthma. GI: No diarhhrea, constipation, vomiting or
nausea. No abdominal pain. GU: No issues with urination. Neuro:
No dizziness, motor issues, lack of coordination, numbness or
tingling sensations. Musculoskeletal: No muscle pain or joint
inflammation. No recent injuries or deformities, no difficulty or
No recent or frequent illness, fatigue, fevers, chills, or night sweats.
States recent 10 pound weight loss due to diet change and exercise
increase.
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pain with movement. Psych: No anxiety, depression or stress.
HEENT
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Subjective
Denies headaches, eye pain or issues, no sinus pressure, sneezing
or runny nose. No mouth or tooth pain, no difficulty swallowing.
No ear pain or discharge. No dandruff or scalp lesions. Pt does
have prescriptive glasses.
Reports no current headache and no history of head injury or acute
visual changes. Reports no eye pain, itchy eyes, redness, or dry
eyes. Wears corrective lenses. Last visit to optometrist 3 months
ago. Reports no general ear problems, no change in hearing, ear
pain, or discharge. Reports no change in sense of smell, sneezing,
epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general
mouth problems, changes in taste, dry mouth, pain, sores, issues
with gum, tongue, or jaw. No current dental concerns, last dental
visit was 5 months ago. Reports no difficulty swallowing, sore
throat, voice changes, or swollen nodes.
Objective
No obvious injuries or bruising. Head is normocephalic. Eyes, ears
and nose symmetrical with no edema. Even hair distribution on the
head and eyelashes. Eyes show no ptosis. PERRLA, fundus and
disc margins clear bilaterally. Snellen 20/20 right eye, 20/20 left
eye with corrective lenses. Extraocular movement intact, normal
convergence. No TMJ noted, no redness to throat, no goiters, or
lymphadenopathy, thyroid smooth. Sinus non-tender to palpation.
Head is normocephalic, atraumatic. Bilateral eyes with equal hair
distribution on lashes and eyebrows, lids without lesions, no ptosis
or edema. Conjunctiva pink, no lesions, white sclera. PERRLA
bilaterally. EOMs intact bilaterally, no nystagmus. Mild
retinopathic changes on right. Left fundus with sharp disc margins,
no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with
corrective lenses. TMs intact and pearly gray bilaterally, positive
light reflex. Whispered words heard bilaterally. Frontal and
maxillary sinuses nontender to palpation. Nasal mucosa moist and
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Whisper test negative, tympanic membrane pearlly gray and intact.
Mouth moist, no sores or thrush, tonsils 2+ bilaterally, uvula
midline, tongue symmetric, gag reflex intact. Nasal cavities moist
and pink.
pink, septum midline. Oral mucosa moist without ulcerations or
lesions, uvula rises midline on phonation. Gag reflex intact.
Dentition without evidence of caries or infection. Tonsils 2+
bilaterally. Thyroid smooth without nodules, no goiter. No
lymphadenopathy.
Respiratory
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Subjective
Pt denies shortness of breath, difficult breathing, wheezing or
cough. Pt has history of asthma. Denies sinus pressure or
rhinnorhea.
Reports no shortness of breath, wheezing, chest pain, dyspnea, or
cough.
Objective
Peak flow x3: FVC 3.91, FEV 3.15= FEV1/FVC ratio of 80.5% Pt
in no obvious distress, breathing unlabored, chest symmetrical, rise
and fall of chest even. Breath sounds clear and equal bilaterally in
all fields. Tympanic resonance to percussion anterior and posterior
chest with no dullness. Fremitus normal.
Chest is symmetric with respiration, clear to auscultation bilaterally
without cough or wheeze. Resonant to percussion throughout. In
office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.
Cardiovascular
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Subjective
Pt denies chest pain, palpitaitons, or edema. No history of anemia
or easy bruising.
Reports no palpitations, tachycardia, easy bruising, or edema.
Objective
S1, S2 heard with normal rate and rythm, no murmurs or gallops
noted on auscultation. Pulses present in all extremeties 2+, no
thrills. No edema in extremities, PMI MCL 5th intercostal space.
Carotid pulsespresent with no bruit. Capillary refill <3 sec in all
extremities. No abdominal, iliac, renal or femoral bruits. No JVD.
Heart rate is regular, S1, S2, without murmurs, gallops, or rubs.
Bilateral carotids equal bilaterally without bruit. PMI at the
midclavicular line, 5th intercostal space, no heaves, lifts, or thrills.
Bilateral peripheral pulses equal bilaterally, capillary refill less
than 3 seconds. No peripheral edema.
Abdominal
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Subjective
Pt denies any nausea, vomiting, diarrhea, constipation, abdominal
pain or discomfort. Reports eating healthier but no change in
appetite. No difficulty urinating or excessive urinating. Denies
bowel or bladder dysfunction.
Gastrointestinal: Reports no nausea, vomiting, pain, constipation,
diarrhea, or excessive flatulence. No food intolerances.
Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria,
flank pain, vaginal discharge or itching.
Objective Abdomen protuberant, symmetric, no visible masses, scars, or
lesions, coarse hair from pubis to umbilicus. Bowel sounds are
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Abdomen no visible brusing or lesions, protuberant, and excessive
hair around umbilicus. Bowels sounds normoactive in all
quadrants. No tenderness, guarding, no masses on deep and light
palpation. Tympanic on percussion and no CVA tenderness.
Organs non-palpable with no masses, liver span palpable at 1 cm
below RCM and 7 cm MCL. No bruit in abdominal aorta, renal
arteries or iliac arteries. Spleen no dullness.
normoactive in all four quadrants. Tympanic throughout to
percussion. No tenderness or guarding to palpation. No
organomegaly. No CVA tenderness.
Musculoskeletal
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Subjective
Pt denies no joint or muscle pain, no weakness or edema.
Reports no muscle pain, joint pain, muscle weakness, or swelling.
Objective
No obvious injuries or deformities. No edema or lacerations. Full
ROM in neck, shoulders, arms, wrists, ankles, hips, spin, knees.
Strenght 5+ bilaterally all extremities.
Strength 5/5 bilateral upper and lower extremities, without
swelling, masses, or deformity and with full range of motion. No
pain with movement.
Neurological
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Subjective
Pt denies any numbness or tingling sensations, denies issues with
coordination and gait. No dizziness, history of seizures. Pt denies
any history of head injuries. Pt denies any loss of sensation.
Reports no dizziness, light-headedness, tingling, loss of
coordination or sensation, seizures, or sense of disequilibrium.
Objective
Graphesthesia, stereognosis intact. Pt alert and oriented x 4.
Memory intact, position sense normal in extremeties. DTR's 2+ in
all extremeties, purposeful rapid alternating movements, normal
cerebellar functioning. Decrease in sensation with monofilament
on bilateral plantar surfaces. Sensation intact Appearance and
behavior appropriate, follow commands and engages in activities.
Point to point movement smooth and accurate for finger to nose
and heel to shin. Gag reflex present.
Normal graphesthesia, stereognosis, and rapid alternating
movements bilaterally. Tests of cerebellar function normal. DTRs
2+ and equal bilaterally in upper and lower extremities. Decreased
sensation to monofilament in bilateral plantar surfaces.
Skin, Hair & Nails
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Subjective
Pt denies rashes, bruising, or lesions. States darkness around neck
is diminishing since birth control and metformin. Denies dandruff
or hair loss. Denies changes in nail beds or brittle nails.
Reports improved acne due to oral contraceptives. Skin on neck
has stopped darkening and facial and body hair has improved. She
reports a few moles but no other hair or nail changes.
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Objective
No obvious injuries, lacerations, rashes, dandruff, or bruising. Pt's
hair well groomed with even hair distribution. No nail deformities
noted in all extremities, clear with no ridges. Excessive hair growth
on umbilicus, thin hair growth on upper lip.
Scattered pustules on face and facial hair on upper lip, acanthosis
nigricans on posterior neck. Nails fre
