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Paper Topic:

History and Physical

RUNNING HEAD : HISTORY AND PHYSICAL

History and Physical

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July 5 , 2010

TMS is a 45-year-old Asian office manager residing in Falls Church Virginia

Referral : None

Source and Reliability : Self-referred reliable historian

Chief Complaint

I felt so dizzy and weak before I pass out

History of Present Problem

This is a 45-year-old female has been recently diagnosed with Type II Diabetes Mellitus in

late 2008 . The patient fainted at the local gym following complains of dizziness , weakness , and headache . She states that she was in an aerobic class when she felt dizzy and fell on the floor . The patient states that she couldn 't miss working out despite feeling fatigue . It is observed that the patient was sweating profusely and lethargic upon arrival at the emergency room . Some relief has been achieved with intake of three glucose tablets

Past Medical History

Generally healthy with exception of hyperglycemia

Medications : Glucophage 500 mg BID and herbal multivitamin daily

Allergies : Denies

Tobacco : None

Alcohol /Illicit drugs /OTC /Herbals : Consumes 1 glass of wine occasionally denies illegal drug use self-medicate with Tylenol for pain takes herbal supplements

Hospitalizations , Illnesses , and Injuries : 1990 Sepsis following CS delivery 1993 Cystitis or UTI

Surgeries : Tubal Ligation (1995

Ob /GYN : Menarche age 13 Classical Caesarian section surgery (1990 and 1993 . Sexually active with same partner for 20 years . Denies any concerns about STD infections

Health Maintenance...

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