Digital Clinical Experience Orientation Tina Jones
Name: Tina Jones Age: 28 years old Ethnicity: AA Gender: F
CC: The patient presents with a need to undergo a comprehensive medical examination (pre-employment physical) because she has recently secured a job with a company. “I came in because I am required to have a recent physical exam for the health insurance at my new job.” She has been hired as an accounting clerk and the health insurance policy with her employer requires that she undergoes a pre-employment physical within the next two weeks. Digital Clinical Experience Orientation Tina Jones
HPI: The patient is a 28 year-old African American female who presents to the facility with the above need. She states that she just recently secured a job at the company called Smith, Stevens, Stewart, Silver & Company as an accounting clerk. Before starting to work, she must first obtain a pre-employment physical examination as a requirement for a health insurance policy taken by the employer. At this visit she denies having any acute concerns. She last saw her provider about four months ago. It was to get her annual gynecological examination results at Shadow Health General Clinic. She reveals that during that visit she was diagnosed for the first time with polycystic ovarian syndrome or PCOS. Because this condition causes hyperandrogenic manifestations and hirsutism, she was given a prescription of oral contraceptives. She says that she is tolerating the medications well ever since they were prescribed to her. She is upbeat and says that she feels wonderful and healthy. She is looking forward to commencing her new job at the company.
- Tylenol 500-1000 mg orally prn for the headaches she often has
- Metformin 850 mg orally BID ( the last dose was on the morning of the hospital visit)
- Albuterol 90 mcg spray MDI 1-3 puffs Q4h prn (the last dose according to her was on the previous day)
- Drospirenone and ethinyl estradiol PO QD (the last use was on the morning of the visit)
- Ibuprofen 600 mg PO TID/ prn (she takes this for her painful menstrual periods and the last time taken was six weeks before)
- She is allergic to penicillin that normally gives her a rash.
- She is also allergic to dust and cat fur.
- She is asthmatic and when exposed to dust and fur she gets rhinorrhea, itchy and swollen eyes, and an exacerbation of the asthma symptoms.
- She does not have any food allergies and is also not allergic to latex rubber.
Past Medical History (PMHx) and Surgical History
She has a history of asthma that was diagnosed when she was just two and a half years old. To control her symptoms and manage exacerbations she uses the short-acting beta agonist (SABA) albuterol (Ventolin) the asthma gets worse and acute when she is exposed to fur and dust. She states that her latest attack or exacerbation was on the previous day. It is the albuterol inhaler that saved her life. Her last hospitalization was in high school because of an exacerbation of the asthma.
She also has a history of type II diabetes mellitus that was diagnosed when she was only 24 years of age. For this she was started on metformin about five months ago. This medication at first made her experience nausea and vomiting but then the gastrointestinal side effects have now faded away. She is doing glucose self-monitoring by taking her blood sugar every morning. This self blood-glucose monitoring (SBGM) is facilitated by a portable glucometer that she bought for that specific purpose on the advice of her provider. Bu a stroke of coincidence, the metformin she is using for glycemic control is also effective in reducing the hyperandrogenic or high male hormone manifestations such as acne and hirsutism or hairy body.
Ms. Jones also has a history of hypertension that she has managed by the lifestyle strategies of exercise and diet only. She has never had any surgeries. For the exercise, she walks for 30-40 minutes 4-5 days every week. She also does swimming with a friend once every week.
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Family and Social History
She just got into a new relationship with a man but has not yet initiated sexual contact. She does not have a child and is not planning on having one just yet. She does not take alcohol and also does not smoke. In her home there are smoke detectors. She also puts on a seatbelt every time she is driving in the car. She does not ride motorcycles. When out in the scorching sun she often uses sunscreen to avoid sunburn. Her parents do have licensed guns and they keep them under lock and key in their bedroom. Digital Clinical Experience Orientation Tina Jones
She states that she finished her childhood vaccines on schedule and has been getting booster doses as required. For instance, she got her tetanus shot within the last one year and also got the meningococcal vaccine while in college not so long ago. She however admits that she is behind on her influenza vaccination.
Review of Systems (ROS)
GENERAL: She denies having lost weight, having fever or chills, and feeling fatigued.
HEENT: She denies experiencing headaches. Negative for blurred and double vision, light sensitivity or visual loss. Denies ear discharge, tinnitus, or loss of hearing. No nasal bleeding, runny nose, or sneezing. She has no sore throat and does not experience difficulty in swallowing. The last dental examination was five months before and the last ophthalmic examination was three months before.
SKIN: Denies ever having a rash or pruritus.
CARDIOVASCULAR: Negative for chest tightness or chest pains. Denies palpitations, pedal edema or any other discomfort around the chest.
RESPIRATORY: Denies coughing, producing phlegm, wheezing, and difficulty n breathing.
GASTROINTESTINAL: Negative for nausea, vomiting, and diarrhea. Also denies anorexia, vomiting blood, passing melena or getting fresh blood-stained stool. Denies abdominal discomfort but confirms regular bowel movements. She had her latest bowel movements the previous night.
GENITOURINARY: Denies having urgency, hesitancy, or frequency. Also denies polyuria and/ or polyphagia. Her first sexual encounter was at the age of 18 years. She identifies as heterosexual and has sex with men. Her LMP was two weeks prior to the hospital visit. She tested negative for sexually transmitted infections (STIs) including HIV/AIDS four months before. Her last Pap smear was also four months before.
NEUROLOGICAL: Negative for dizziness, pins and needles, ataxia, one-sided weakness or numbness. Her bladder and bowel control are still intact.
MUSCULOSKELETAL: She has lost the use of both of her feet. Reports frequent myalgia, arthralgia, back pain and stiffness of the joints.
HEMATOLOGIC: She denies having a history of blood or clotting anomalies. Negative for bruising and/ or bleeding.
LYMPHATICS: Denies having swollen glands or a history of splenectomy.
ENDOCRINOLOGIC: She does not have a history of heat or cold intolerance. Also denies excessive sweating, excessive thirst, or excessive passage of urine. Digital Clinical Experience Orientation Tina Jones
Vital signs: BP 128/82 regular cuff and sitting; P 78, regular; T 99.0°F; RR 15, non-labored; SpO2 99%; Ht. 170 cm; Wt. 84 kg; BMI 29.0 kg/m2 (normal BMI).
General: She is concious, alert and oriented in time, space, place, and person. Her dressing is suitable for the time of day and weather. Her speech is coherent and goal oriented.
HEENT: The head is normocephalic and shows no signs of trauma. The pupils are equal, round, and reacting to light and accommodation (PERRLA). The tragus and pinna show no tenderness. The tympanic membranes are non-perforated and demonstrate a normal light reflex bilaterally. There is no fluid level seen behind the tympanic membranes on both sides. The nostrils are not inflamed with the turbinates intact. She is not sneezing and has no signs of nasal discharge. There is no exudate found on examining the throat which is also not erythematous.
Chest/Lungs: On auscultation, the chest is clear with no wheezing. There are no crepitations, rales, or rhonchi.
Heart/Peripheral Vascular: The heart sounds S1 and S2 audible on auscultation with regular rate and rhythm. Abnormal sounds such as murmurs, gallop, or rub not heard.
- Lab: CRP 1 mg/L; WBC 6,700 with no leucocytosis.
- Radiology: X-ray of the chest reveals no abnormalities.
- Hb 14.1 g/dL
If I had to do it all over again, I would not change anything about the way I performed Tina Jones’s interview and evaluation. Taking a patient’s history and doing a physical examination (whether for medical, psychiatric, or surgical reasons) follows a predetermined path. I took sure to follow this method to the letter when evaluating the patient. In addition, I performed a thorough medical examination and documented my findings. I upheld the bioethical principle of autonomy, which includes informed consent, by seeking informed consent for all treatments. I also demonstrated beneficence by ensuring that the patient was as comfortable as possible. I advised the patient to keep exercising and eat a diet rich in fruits and vegetables that was free of processed foods.
Digital Clinical Experience Orientation Tina Jones