Comprehensive Health History and Physical Examination Guidelines.

Chief complaint: a pre-employment physical after securing a new employment.

HPI: the patient is an African American aged 28 years old who came for pre-employment physical after securing employment at Smith, Stevens, Stewart, Silver & Company. She reports no concerns today. Her last healthcare visit was 4 months ago when she was diagnosed with POS and placed on oral contraceptives. She is a well-known diabetic patient. And achieves glycemic control with diet, metformin, and exercise.Comprehensive Health History and Physical Examination Guidelines.

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Past Medical and Surgical History: At 21/2 years she was diagnosed with asthma. She uses an albuterol inhaler for symptom control. She has had one hospitalization in high school secondary to asthma. T2DM was diagnosed at 24 and five months ago, she started metformin and has good glycemic control. She had a history of hypertension that gradually resolved with lifestyle modification. She went for a dental, eye exam, and Pap smear five, three, and four months ago respectively. Up to date with all immunizations apart from influenza and human papillomavirus immunizations. She is certain that she is up to date with childhood vaccines.Comprehensive Health History and Physical Examination Guidelines.

OB/GYN: First sexual encounter (sex with men) at 18 years, is heterosexual, menarche at 11 years. Para 0+0, LMP-two weeks ago. Diagnosed with POS four weeks ago. After placement on oral contraceptives, most symptoms have resolved. Four months ago, she tested negative for STIs, HIV/AIDS.

Medications and Allergies: rash-penicillin.  She is allergic to dust and cats (itchy, exacerbated asthma symptoms, runny nose, and itchy). She denies latex and food allergy. Comprehensive Health History and Physical Examination Guidelines.

Medications:

1. Drospirenone and Ethinyl estradiol PO QD (used last this morning).
2. Acetaminophen 500-1000 mg PO prn (for headaches).
3. Fluticasone propionate, 110 mcg 2 puffs BID (used last this morning).
4. Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (used last three months ago).
5. Metformin, 850 mg PO BID (used last this morning).

Family History: Her mother (50) years with elevated cholesterol and hypertension. Deceased father at 58 (high cholesterol, hypertension, and type 2 diabetes). Her brother Michael is alive and well, overweigh at 25. Her sister Britney is asthmatic, 14 years. Her maternal grandmother deceased at 73 (stroke, hypertension, and high cholesterol). Her maternal grandfather died at 78 years of a stroke. He also had a history of hypertension and high cholesterol. Paternal grandmother alive, hypertensive, and well (82 years)? Her paternal grandfather deceased at 65 years (colon cancer, type 2 diabetes). Her paternal uncle as is an alcoholic).Comprehensive Health History and Physical Examination Guidelines.

Social History: Safety: at home, she has smoke detectors, uses a seatbelt, and sunscreen. She has never married; she has no children. Since she was 19 years old, she has been living independently. Currently, she stays with her sister and mother in a single-family setup. Ms. Jones enjoys the company of friends attending Bible Study, reading, and volunteering in the church which provide a strong social support system. She denies smoking tobacco. From 15-21 years of age, she used cannabis. Denies using heroin, methamphetamines, and cocaine. When out with friends, she uses alcohol around 2-3 times in a month but denies drinking more than three drinks in an episode. Recently, she denies a history of foreign travel. She does not keep pets. She engages in mild-moderate exercise 4-5 times weekly (swimming or yoga). Reports a decrease in stress, and an increase in the ability to sleep and cope. Denies feeling anxious, depressed, or suicidal thoughts.Comprehensive Health History and Physical Examination Guidelines.

Review of Systems:

General: Denies fatigue, weakness. Reportedly feels that she has lost weight since she started to observe a healthy lifestyle.

Neurological: AOX3, PEBRL, coherent and clear speech. Safety awareness with appropriate judgment. Denies decreased sensation and numbness.

Nutrition/Hydration: Ms. Jones appears to be well hydrated and nourished. She reports observing a healthier lifestyle.

Skin, Hair, Nails: reports excess growth of body and facial hair since she started taking Yaz. Denies mole changes, brittle nails, or hair.Comprehensive Health History and Physical Examination Guidelines.

HEENT: She uses corrective lenses. Denies headaches. Denies changes in vision since she underwent an eye exam four months ago. Denies tinnitus and loss of hearing. She had an ear infection when she was a child. Denies any changes in taste or smell. Denies dysphagia and her last dental exam was five-month ago

Resp: she is asthmatic. The last asthma exacerbation was three months ago. Denies DIB wheezing, dyspnea, SOB, or coughing.

Cardiac: no adventitious sounds, denies palpitations, edema, arrhythmias. Denies a history of cardiovascular disease.

GI: non-tender and soft abdomen. Non-distended. Denies diarrhea or constipation. The last bowel movement was yesterday. The normal bowel pattern is in every 1-2 days. Normal bowel movements. Denies mucus or blood in the stool.Comprehensive Health History and Physical Examination Guidelines.

GU denies hematuria, urinary frequency, and dysuria. Denies foul-smelling discharge. Denies UTI history.

Female Genitalia: currently, she is on Yaz to control the symptoms of POS.  These symptoms are; heavy menses, an irregular menstrual cycle, and severe cramping. Since initiation to oral contraceptives.  The symptoms have continuously improved. Currently, she denies a history of fevers, fatigue, night sweats, or chills. Following dietary changes and mild-moderate physical exercise. Ms. Jones reports losing 10 pounds. The periods are currently regular. LMP two weeks ago. She has never been pregnant. Denies the history of HIV/AIDS and STIs.  Her last pap smear was four months ago.  Currently, she denies sexual activity but strongly believes that she will be sexually active with her new partner soon. She reports that she practices safe sex.Comprehensive Health History and Physical Examination Guidelines.

Musculoskeletal: she reportedly sustained a foot injury after slipping off from a stool at a time when she had gait issues. Currently, she denies having any problems with her gait. All joints have a FROM. Denies joint weakness, swellings, pain, or restricted movement.Comprehensive Health History and Physical Examination Guidelines.

Objective Data

Vital Signs:

Temp: 99.0 F

HR: 78

RR: 15

BP: 128/82

SpO2: 99% (room air)

Pain: Denies Pain

Height: 170 cm

Weight: 84 kg

BMI: 29

Random Blood Glucose: 100 mg/dl

Physical Examination

Ms. Jones is AOX3. She is well-groomed.  Is cooperative and engages easily in conversations. She has a pleasant mood. She has no facial fasciculation nor tics. She has a fluent speech with clear words.Comprehensive Health History and Physical Examination Guidelines.

HEENT: Head- atraumatic and normocephalic, bilateral eyes. Pink conjunctiva, with white sclera, PERRLA. Intact and non-nystagmus EOMs. Snellen: 20/20 left eye, 20/20 right eye with corrective lenses. Bilateral pearly gray and intact TMs, with a positive light reflex. Non-tender frontal and maxillary sinuses on palpation. Pink and moist nasal mucosa, midline septum. Moist oral mucosa, no lesions or ulcerations, on phonation, the uvula rises midline. Intact gag. No signs of caries or infection on the dentition. Bilaterally, tonsils 2+. Smooth thyroid with no goiter or nodules. No lymphadenopathy.

Respiratory: Symmetrical chest with respiration. On bilateral auscultation, the lungs are clear. On percussion, the chest is resonant, In-office spirometry.Comprehensive Health History and Physical Examination Guidelines.

CV:  heart rate-regular with no rubs, or gallop. S1 and S2 were heard.  Bilaterally, the bilateral carotids are equal, with no bruits.   PMI- 5^th ICS, no heaves and lifts. Bilaterally equal peripheral pulses, no peripheral edema, and capillary refill is < three seconds.Comprehensive Health History and Physical Examination Guidelines.

Abdomen: symmetric, non-distended, normoactive bowel sounds. On percussion, there is a consistent tympanic. On palpation, there’s no guarding or tenderness. No CVA tenderness, no organomegaly.

Neurological: Bilateral lower and upper extremities have a strength of 5/5. Stereognosis and graphesthesia are normal with movements that rapidly alternating bilaterally. The cerebellar function is normal. There is a decreased sensation of monofilaments in bilateral plantar surfaces. DTRs 2+ and bilaterally equal in the lower and upper extremities.Comprehensive Health History and Physical Examination Guidelines.

Musculoskeletal: No masses, swelling, or deformities on bilateral lower and upper extremities. All joints have FROM and are non-tender with movement.

Skin, hair, and nails: She has pustules scattered on her face and facial hair on the upper lip. On the posterior neck, she has acanthosis nigricans

Assessment: Ms. Jones presented for a pre-employment physical general/physical exam. Currently, she takes flovent, metformin, and proventil. She uses assistive lenses, and sleeps well. She started keeping her asthma records by tracking her rescue inhaler usage, and regularly monitoring her peak flow. Currently, she is in a relationship, using birth control that also helps in controlling her POS.Comprehensive Health History and Physical Examination Guidelines.

Primary Diagnosis: (none) Pre-employment physical

Plan: Currently none (Ms. Jones was here for a basic physical and health examination).Comprehensive Health History and Physical Examination Guidelines.