MS Jones is a 28 year old African American woman who presented for a pre-physicalShe is the primary source of the health information and freelyProvides the informationHer speech is clear and coherent

She maintains eye contact throughout the interviewGeneral SurveyMs. Jones is alert/oriented to time, place, event and personShe is appropriately dressed and does not manifest any distressReason for VisitHistory of Present IllnessMs. Jones is a 28 –year old African American woman who presentedFor a pre-employment physical.She is the primary source of the health information and freely provides the information.Her speech is clear and coherentShe maintains eye contact throughout the interview.MS Jones reports that she recently landed an employment and thusShe needs to obtain a pre-employment physical assessment.She denies any pain acute illness, pain or discomfort.PAST MEDICAL HISTORYDiabetesPCOSAsthmaAllergiesMedicationsMetformin: 850 mg BIDFlovent:    2 puffs 88 mcg/spray BIDAlbuterol: 90 mcg/spray MDI 2 puffsIbuprofen 600 mg PO TIDMedical HistoryAsthma diagnose 2 years ago uses albuterol. Last exacerbationWas 3 months ago?Type 2 diabetes diagnose at 24 years old, started metformin 5 monthsAgoHas a history of hypertensionDiagnosed with PCOS four months agoFamily HistoryNever marriedHas a boyfriendEnjoys attending church activities and spending time with friendsNo tobacco or any drugs useSocial drinkerEats healthy dietPhysically activeMother: Hypertension, high cholesterolFather: Deceased at 58, hypertension, type 2 diabetes, highCholesterolBrother: OverweightSister: AsthmaMaternal grandmother: Succumbed to stroke, history ofHypertension, high cholesterolMaternal grandfather: died of stroke, history of high blood pressure andHigh cholesterolPaternal grandmother: High Blood pressure and high cholesterolPaternal grandfather: colon cancer, high blood pressure, diabetesHealth MaintenanceLast Pap smear 4 months agoLast dental exam, 5 months agoImmunizations: Tetanus booster within the last year, influenza not updatedConsumes healthy diet and engages in exercisesMental HistoryReports reduced stressDenies depression or anxietyOrient to time, place, person and eventFluent speechSubjective:Reports no current headacheNo visual changesReports no change in smellNo current dental problemsDenies no soar throatDenies any difficulty swallowingCardiovascular:Denies chest pain, dyspnea on excretion, edema, lightheadness, Scalp is normalHeart rate is regular without murmurs, rubs or gallopsBilateral carotids equal without bruit.Bilateral peripheral pulses equal bilaterallyCapillary refill less than 3 secondsPMI at the midclavicularHead is normocephalicBilateral eyes: sclera white, no cross eyes.Conjunctivitis pinkOral mucosa pinkGag reflex intactThyroid smooth with nodules, no lypadedenopathyFrontal and maxillary sinuses nontender to palpateRespiratory:No cough, crackles, hemoptysis, no sob, no cough, no wheezing, chest isSymmetric with respiration clear to auscultation bilaterallyResonant to percussion throughoutGastrointestinalDenies: abdominal pain, constipation, diarrhea, flatus, melena, nausea, vomitingMusculoskeletalReports: no symptoms (neck pain, shoulder pain back pain, upper extremity pain –Lower, extremity pain joint swelling, denies muscle pain, muscle weakness or swellingSkin:Reports: improved acne after using oral contraceptives.Skin and neck has stopped darkening and facial and body hair has improved. Denies any nail changes. No symptoms pruritus denies cyanosis, diaphoresis, dryness jaundice, mottledNo rashes, sores. nail free of ridges or abnormalitiesNeurological:Reports: no symptoms gait disturbance, tremors,Denies aphasia, confusion, numbness, speech changes, tingling. Loss of coordination, seizures or sense of disequilibrium.Psychiatric:Reports: No cravings (ETOH) depression, denies agitation, anxiety, hallucinations, Homicidal ideation, mood lability, suicidal ideation;EndocrineDenies cold intolerance, heat intolerance, denies polydipsia, denies polyphagia,\