HX-40%
Physical-40%
Problem list-20%
HPI ( h istor y of p re se nt illn e ss)
C hi e f c o m pl a i nt :
Yearly physical
HPI:
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has nocomplaints.
.
PMH ( p r e viou s me dic al h ist or y)
Allergies:
None
Other ac ti ve p r o b l e m s :
Bilateral fibrocystic breast changes
M e d i c a l , s u r g i c a l , o b s t e tr i c , h o s p i t a l i z a t i o n s :
Medical: None
Surgical: G2P2; Bilateral tubal ligation following last delivery at age 35
OB/Gyn: NSVD x two; breast fed both for 4 months; premenopausal; menses regular since age 10.5
P r e ve nt i ve Healt h:
Pap smears in the past are negative Diet:
Tries to eat a well-balanced diet
Exercise: Walks to and from the train 5 days a week; weekend gardeningUp-to-
I m m un i z a ti o n s :
date
Vitamin E
Ibuprophen occasionally for headaches
Family Hx
Father: Hypertension, hyperlipidemia
Mother: Hx of type 2 diabetes Sisters:
No sisters
Brothers: Healthy and very physically active
Social Hx
Ethnicity: Hispanic-American
Occupation: Middle-school learning specialistMarital
status: Married x ~13 years
Children: 2 sons (5ish and 7ish)
Tobacco: Never
Recreational drugs: Never
Alcohol: Wine (one glass at dinner most days)
, ROS ( r evie w of sys te ms)
G e ne r a l / C o ns t i t ut i o n a l:
Normal energy level
No sleep concerns
Weight stable
S ki n /B re a st:
Negative except for lumpy breasts
HE EN T & Nec k:
Negative
Cardiovascular:
Negative
R es pi ra t or y:
Negative
Abdomen/ Gastrointestinal:
Negative
G e n i t o u r i nary:
Negative
Musculoskeletal:
Negative
Neurological:
Negative
Al l e r gi c / I m m u n o l o g i c :
Negative
L y m pha ti c/ E n d o c r i n e :
Negative
He mat ologic:
Negative
Psychological:
Negative
Vit al s
Temp: 98.6 F
Pulse: 72, rhythm: regular
BP: left: 130/72
Respiration
: 14, effort: unlabored
Ph ysic al Exam
Wei ght:
148.0 pounds
S ki n /B re a s t :
No pallor, jaundice, ecchymoses, or rash
Normal, symmetrical breast contour
No visible skin or nipple abnormalities
No spontaneous or expressed nipple discharge or blood
Irregular "lumpy bumpy" consistency through both breasts; no suspicious, discrete palpable lesionsSlight
tenderness to exam reported
Physical-40%
Problem list-20%
HPI ( h istor y of p re se nt illn e ss)
C hi e f c o m pl a i nt :
Yearly physical
HPI:
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has nocomplaints.
.
PMH ( p r e viou s me dic al h ist or y)
Allergies:
None
Other ac ti ve p r o b l e m s :
Bilateral fibrocystic breast changes
M e d i c a l , s u r g i c a l , o b s t e tr i c , h o s p i t a l i z a t i o n s :
Medical: None
Surgical: G2P2; Bilateral tubal ligation following last delivery at age 35
OB/Gyn: NSVD x two; breast fed both for 4 months; premenopausal; menses regular since age 10.5
P r e ve nt i ve Healt h:
Pap smears in the past are negative Diet:
Tries to eat a well-balanced diet
Exercise: Walks to and from the train 5 days a week; weekend gardeningUp-to-
I m m un i z a ti o n s :
date
Vitamin E
Ibuprophen occasionally for headaches
Family Hx
Father: Hypertension, hyperlipidemia
Mother: Hx of type 2 diabetes Sisters:
No sisters
Brothers: Healthy and very physically active
Social Hx
Ethnicity: Hispanic-American
Occupation: Middle-school learning specialistMarital
status: Married x ~13 years
Children: 2 sons (5ish and 7ish)
Tobacco: Never
Recreational drugs: Never
Alcohol: Wine (one glass at dinner most days)
, ROS ( r evie w of sys te ms)
G e ne r a l / C o ns t i t ut i o n a l:
Normal energy level
No sleep concerns
Weight stable
S ki n /B re a st:
Negative except for lumpy breasts
HE EN T & Nec k:
Negative
Cardiovascular:
Negative
R es pi ra t or y:
Negative
Abdomen/ Gastrointestinal:
Negative
G e n i t o u r i nary:
Negative
Musculoskeletal:
Negative
Neurological:
Negative
Al l e r gi c / I m m u n o l o g i c :
Negative
L y m pha ti c/ E n d o c r i n e :
Negative
He mat ologic:
Negative
Psychological:
Negative
Vit al s
Temp: 98.6 F
Pulse: 72, rhythm: regular
BP: left: 130/72
Respiration
: 14, effort: unlabored
Ph ysic al Exam
Wei ght:
148.0 pounds
S ki n /B re a s t :
No pallor, jaundice, ecchymoses, or rash
Normal, symmetrical breast contour
No visible skin or nipple abnormalities
No spontaneous or expressed nipple discharge or blood
Irregular "lumpy bumpy" consistency through both breasts; no suspicious, discrete palpable lesionsSlight
tenderness to exam reported
