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Documentation / Electronic Health RecordDocumentationVitalsStudent DocumentationModel Documentation128 / 82, 78, 15, 37.2 C, 99% ra ,N/AHealth HistoryStudent DocumentationModel DocumentationIdentifying Data & ReliabilityTJ, AA Female, 02/17/1991 she is a good historian and answers questions appropriately. N/AGeneral SurveyTJ 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.N/AReason for VisitCC: physical exam for new job N/AHistory of Present IllnessHPI: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.N/AMedicationsMedication: 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 N/A
Student DocumentationModel Documentationday for crampsAllergiesAllergies: Penicillin-rash and hives Cats- rash/hives/itching/troublebreathingN/AMedical Historymedical: DM dx age 24, Asthma: dx age 2.5 HX of HTN in past, no medication Surgical: denies past surgeriesN/AHealth MaintenanceHad pap smear and physical exam five months ago. both normal. does not do breast self-exams.N/AFamily HistoryFH: mother has Hyperlipidemia and HTN Father deceased x 1 yearin car accident. grandmother HTN, Grandfather dies from cancer, dx HTN, DM brother is obese sister has asthmaN/ASocial HistorySH:T.J. is a single female, never married, lives with mother, deniessexual 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 employmentN/AMental Health History