Student Response Model Documentation

Identifying Data & Reliability

Ms. Jones communicates in English as her primary language. She is a good historian who visited the clinic for a medical checkup to that is needed for her medical insurance. She has a Degree in BA, and she is currently working as an accounting clerk ( Inzucchi et al., 2012). Having last hospitalized for four months for pain in her right foot, she is currently okay with no complications. 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

She depicts a pleasant, calm and cooperative appeal. She depicts an erect posture with no fever, no chills and has no dyspnea. 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.

Reason for Visit

She came for a thorough physical test that should be used in determining her insurance scheme to meet her anticipated job. "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

She has no recent illness. 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 health care 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

She was previously consuming Metformin 850 mg PO BID -Flovent 88 mcg 2 puffs BID -Proventil 90 mcg 2 puffs PRN and Advil PO PRN for cramps but she did not continue with the dose since she started using birth control pills. 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)

Allergies

She is irritated by cats and develops rush for prolonged association with cats. She also develops asthma due to dust. Penicillin: rash Denies food and latex allergies Allergic to cats and dust. When she is exposed to allergens, she states that she has a runny nose, itchy and swollen eyes, and increased asthma symptoms.

Medical History

At 16 she was also diagnosed with Asthma exacerbation but did not show any sign of intubation. She was diagnosed with type 2 diabetes at her 24 and hypertension during her last six months, but she is under controlled diet and exercises. She was also diagnosed with Polycystic Ovarian syndrome like six months ago. 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, identify 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 a 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

For the last four months, she has reported a significant weight loss of 10lbs since she eats fewer carbs, low fats take more vegetables among other junk foods. She now depicts that she is controlling her diabetes due to healthier foods and performing exercises (Woods et al., 2013). 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 college. Safety: Has smoke detectors in the home, wears a seatbelt in the car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in parents room.

Family History

Her family health history shows that her Paternal grandfather died at age 65 due to colon CA, diabetes and hypertension, her Paternal grandmother is 82 years old, and she has high cholesterol and hypertension. Herat attack took her maternal grandfather at 80 which was accompanied by hypertension and high cholesterol content. Also, her maternal grandmother died at 73 due to stroke, father died at 58 in a car accident but had hypertension and diabetes. Her mother is alive but living with high cholesterol and hypertension. Her sister is 15 and has asthma. 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

She is a Baptist, she has never smoked cigarettes but reports to have smoked marijuana since her 20th year and did it for about 6 years. Takes alcohol occasionally. She is not sexually active, but she uses birth control pills. 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 at 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 with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and 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

Does not show any depression, mental illness, stress, suicidal ideation. 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. The mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear.

Review of Systems - General

She does not show any skin rash, hair loss, no itching, dizziness or chain pain. She does not depict numbness and no mammogram report. No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10-pound weight loss due to diet change and exercise increase.

HEENT Student Response Model Documentation

Subjective

She does not have a history of head or neck injury but started wearing glasses three months ago but does not have any itching or discharge from her eyes. No nose is bleeding, swallowing difficulties or mouth pain. 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 optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in the 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

She has a normal scalp with symmetric, no lesion. Her ears are well aligned, has well moist eyes, moist conjunctive EOM with no nystagmus. She also has 5/5 cervical lymph node. No palpable nodes throat. Has healthy dental formula with no gap. Tongue rises and falls with the gag reflex. 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, the white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on the 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 non tender to palpation. Nasal mucosa moist and 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 Student Response Model Documentation

Subjective She does not show any difficulties in breathing. Reports no shortness of breath, wheezing, chest pain, dyspnea, or a cough.

Objective Has healthy lungs with her lungs showing that she has anterior and posterior percussion. She also has a symmetrical thoracic expansion. The chest is symmetric with respiration, clear to auscultation bilaterally without a cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Cardio Student Response Model Documentation

Subjective No chest pain, heart attack, irregular rhythm or heart failure. Reports no palpitations, tachycardia, easy bruising, or edema.

Objective PMI non-displaced, no abnormal heart sounds and no heaves or lifts (Butterworth., Mackey & Wasnick, 2013). Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally withou...