Identifying Data & Reliability
Ms. Tina Jones is a 28 years old African American female who came into the clinic for
pre-employment assessment. she came in alone, alert, and oriented X4, speech is clear
and appropriate for her age makes eye contact. Patient dressed appropriately for the
weather. Ms. Jones tolerated the assessment with ease.
General Survey
Patient is oriented to time, place, and situation. Patient is obese but practicing healthy
eating and physical activity in her daily routine. Patient appears not to be in distress.
She is excited to start her new jo in the city.
Reason for visit
Patient verbalized “I came in here because, I’m required to have a recent physical
examination for the health insurance at my new job.”
History of Present illness
The patient is here, for physical assessment for work insurance for a new job. Patient
presents with other health issues that is under control. She wears a prescription glasses
to help with blurry vision and headaches.
Medications
, Metformin 850 mg- started 5 months ago. BID to manage diabetes type 2, she takes
yogurt with this medication, which helps with stomach upset.
Albuterol 90 mcg/spray MDI -two puffs every 4 hours PRN- inhaler to manage asthma
exacerbation.
Fluticasone Propionate 88 mcg/spray- BID to manage asthma
YAZ- 1 pill every morning- for birth control and to manage PCOS
Advil - 2 tabs. for menstrual pain and headaches.
Allergies
Penicillin – Rash, hives, last taken as a childhood.
Cat – aggravates asthma symptoms.
Patient denied food, seasonal, and latex allergy.
Medical History
Asthma: since childhood, takes albuterol, and Proventil.
Diabetes type 2: diagnosed at age 24 years. Takes metformin and daily blood sugar
checks in the mornings and results normally in 90s.
PCOS: takes Drospirenone and ethinyl estradiol
Hypertension: normal blood pressure readings.
Near sighted and blurry vision- wears glasses to help with vision.
Health Maintenance
Patient has been eating healthy, using recipes from online for diabetes. she is limiting
carbohydrates "staying away from sweets and increasing vegetables".
Typical meals daily include:
Breakfast – Smoothie, fruit, yogurt, and eggs.
Lunch – Sometimes left-over dinner or wheat bread sandwich.
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