Completed |shadow health | 2022 | 11 pages

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Patient Initials: ___TJ____ Age: _28___ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Patient Tina Jones is here today for a preemployment physical. History of Present Illness (HPI): N/A ... Medications: Flovent MDI 2 times per day. Last dose this morning. Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. Last dose 3 months ago. Metformin 850 mg 2 times per day. Last dose this morning. Birth control. Oral contraceptive Drosperinone ethinyl estradiol 1 tablet every morning with breakfast. Last dose this morning. Ibuprofen 1 or 2 tabs every 6 hours PRN pain. Only takes occasionally. Has not taken recently. Tylenol Extra strength 500 mg gel tabs. Takes 1 tab about once weekly for headache. 3 Allergies: PCN - Rash. Last incident in childhood. Cats - Asthma exacerbation Dust - Sneezing and asthma. Denies allergy to latex, food, or other environmental triggers. Past Medical History (PMH): DM2 - Patient was diagnosed with type 2 diabetes at age 24. She was started on Metformin. She did not tolerate metformin well and therefore was non-compliant and stop taking it on her own. She had some complications of diabetes including a right foot ulcer that healed slowly. Months ago, she was placed on Metformin 850 mg b i d. She has been watching her diet. Exercising. She checks her blood sugars every morning. No recent HgA1c. Asthma - Onset at 2 years of age. Describes frequent exacerbations in childhood. Was placed on Proventil Inhaler which she states has greatly reduced exacerbations. Last exacerbation 3 months ago. [Show More]

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