CovingtonLWK9Assgn3.docx - Vitals Student Documentation Model Documentation Height 170 cm Weight 84 kg BP 128\/82 HR 78 RR 15 Pulse Ox 99 Temperature

CovingtonLWK9Assgn3.docx - Vitals Student Documentation...

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Vitals Student Documentation Model Documentation Height: 170 cm Weight: 84 kg BP: 128/82 HR: 78 RR: 15 Pulse Ox: 99% Temperature: 99.0 F or 37.2 C Health History Student Documentation Model Documentation Identifying Data & Reliability Ms. Jones is a pleasant 28-year old African American female who presented to the clinic for a pre-employment physical. Ms. Jones is the primary source of the health history. She freely offers information and her speech is clear and coherent. She also maintained her eye contact throughout the interview. General Survey Ms. Jones is alert and oriented x 3 and is positioned upright on the exam table. She does not appear to be in any distress. She also appears well-nourished and she dresses appropriately with good hygiene. Reason for Visit Ms. Jones states she came in because she is required to have a physical assessment for insurance for her new place of employment. History of Present Illness Ms. Jones reports that she has recently obtained a new job at Smith, Stevens,
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Student Documentation Model Documentation Stewart, Silver & Company. She also reports she needs to obtain a pre- employment physical prior to beginning her employment. Her last visit to a healthcare provider was 4 months ago when she received an annual gynecological exam. Ms. .Jones stated the gynecologist diagnosed her with polycystic ovarian syndrome and started her on the birth control Yaz. She states that it has been tolerated well. Ms. Jones has diabetes mellitus type 2 and is controlling it with diet, exercise, and Metformin. She states she began the Metformin 5 months prior. She reports no adverse effects of the medication. She states she feels healthy and is taking better care of herself than she had been in the past. She is also looking forward to beginning her new job. Medications Metformin 850 mg BID- las dose this am Yaz- 1 tab daily in the am- last dose this am Albuterol inhaler- 2-3 puffs as needed- last use 3 months ago. Flovent inhaler- twice daily Ibuprofen for menstrual cramps Allergies Penicillin Cats and dust exacerbate her asthma symptoms. Denies food and latex allergies.
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