Documentation / Electronic Health Record
Documentation
Vitals
Student Documentation
Model Documentation
128 / 82, 78, 15, 37.2 C, 99% ra ,
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Health History
Student Documentation
Model Documentation
Identifying Data & Reliability
TJ, AA Female, 02/17/1991 she is a good historian and answers
questions appropriately.
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General Survey
TJ is a 28-year-old AA female casually dressed for the season. She
is alert, calm and cooperative sitting erect on exam table. steady
gait observed during assessment.
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Reason for Visit
CC: physical exam for new job
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History of Present Illness
HPI:28-year-old African American female who is requesting
physical exam for a new job. she states she has been feeling good
with no illness and no health concerns.
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Medications
Medication: Metformin 850mg BID Proventil- 90mcg Inhaler as
needed for asthma, last use 3 months ago Flovent- two inhalations
daily BID, Yaz birth control daily for PCOS. Advil 600mg 3x per
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Student Documentation
Model Documentation
day for cramps
Allergies
Allergies: Penicillin-rash and hives Cats- rash/hives/itching/trouble
breathing
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Medical History
medical: DM dx age 24, Asthma: dx age 2.5 HX of HTN in past,
no medication Surgical: denies past surgeries
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Health Maintenance
Had pap smear and physical exam five months ago. both normal.
does not do breast self-exams.
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Family History
FH: mother has Hyperlipidemia and HTN Father deceased x 1 year
in car accident. grandmother HTN, Grandfather dies from cancer,
dx HTN, DM brother is obese sister has asthma
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Social History
SH:T.J. is a single female, never married, lives with mother, denies
sexual activity now, 3 sexual partners in past, denies tobacco use,
social drinker 1-2 times week, 2-3x per month 2-3 drinks, denies
illicit drug use, exercise 4-5 times per week for 30 minutes,
describes diet as good (low fat, sodium). reports caffeine 1-2 time
per week. college degree and just started new employment
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Mental Health History
