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A comprehensive health assessment of an individual, covering a wide range of medical aspects. It delves into the patient's current health problems, past medical history, medication usage, allergies, lifestyle factors, and a thorough review of various body systems. The assessment provides detailed information about the patient's diabetes management, asthma control, birth control usage, and overall health status. It highlights the patient's adherence to recommended healthcare practices, such as regular check-ups, vision examinations, and breast self-exams. The document also explores the patient's dietary habits, physical activity, and substance use, offering insights into their overall well-being. This comprehensive assessment can serve as a valuable resource for healthcare professionals to understand the patient's health profile, identify potential areas of concern, and develop personalized treatment or management plans.
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Asked about current health problems - correctly answered Denies current acute health problems Reports diabetes Reports asthma Asked about last visit to a healthcare provider - correctly answered Reports last visit to a healthcare provider was 4 months ago Reports reason for last visit was annual gynecological exam Reports last general physical examination was 5 months ago Asked about current prescription medications - correctly answered Reports taking diabetes medication Reports having an inhaler Reports taking prescription birth control pills Followed up about diabetes medication - correctly answered Reports diabetes medication is metformin Reports starting taking diabetes medication 5 months ago Reports that side effects of diabetes medication abated over time Reports taking diabetes medication twice daily
Reports diabetes medication dose is 850 mg Denies adverse effects of diabetes medication Asked about asthma medication - correctly answered Reports asthma medication has not changed Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week Reports recommended dose is 1-3 puffs as needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms Denies adverse effects of asthma medication Followed up about birth control prescription - correctly answered Reports starting birth control 4 months ago Reports reason for birth control was to manage PCOS symptoms Reports birth control is drospirenone and ethinyl estradiol (Yaz) Reports taking birth control pill daily
Reports recently beginning exercising to manage diabetes Asked about blood glucose monitoring - correctly answered Reports checking blood sugar once a day Reports checking sugar in the morning Reports using glucometer Reports blood sugar number is usually around 90 Reports having adequate supplies Asked about asthma symptoms - correctly answered Denies change in asthma symptoms Reports belief that asthma is well-controlled Denies current asthma symptoms Reports last use of Proventil inhaler was yesterday Asked about vision - correctly answered Reports optometrist visit Reports last optometrist visit was 3 months ago Reports recently prescribed eyeglasses Reports that glasses improve overall vision
Asked about reproductive system - correctly answered Reports last menstrual period was 2 weeks ago Reports menstrual cycle is normal Reports rare cramping Asked about breast health - correctly answered Reports doing occasional breast exams Denies having a mammogram Denies changes to breasts Denies history of breast cancer Asked about weight changes - correctly answered Reports recent weight loss Reports weight loss of about 10 pounds Asked about diet - correctly answered Reports a typical breakfast is smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt Reports a typical lunch is dinner leftovers or tuna or chicken sandwich on wheat bread Reports a typical dinner is vegetables with a protein and brown rice or quinoa Reports a typical snack is carrot sticks or an apple Asked about caffeine intake - correctly answered Denies drinking coffee
- correctly answered Denies fatigue Denies fever Denies chills Denies current sleep issues Denies night sweats Denies swelling Asked about HEENT - correctly answered Denies general HEENT issues Asked about review of systems for respiratory - correctly answered Denies current breathing problems Reports occasional shortness of breath Reports occasional wheezing Reports occasional chest tightness Denies pain while breathing Denies coughing Asked about review of systems for cardiovascular - correctly answered Denies cardiovascular issues Asked review of systems for gastrointestinal - correctly answered Denies gastrointestinal issues
Asked review of systems for genitourinary - correctly answered Denies genitourinary issues Asked review of systems for musculoskeletal - correctly answered Denies musculoskeletal issues Asked review of systems for neurological - correctly answered Denies neurological issues Asked review of systems for skin, hair and nails - correctly answered Denies integumentary issues