Laura, 40yo, F
S.
CC-
fatigue, weight loss, nausea, changing skin color
HPI-
Laura has been feeling bad for a few weeks now, thought it was the flu. She denies fever
but has been nauseous. Now she notices her skin color has a funny tinge to it. She reports
decreased appetite and nausea for 3 weeks; she has lost 5 pounds, muscle aches and stomach
cramps. She has taken Ibuprofen for her aches and pains but no other OTC medications.
Current medications-
daily multivitamin, fish oil, and CoQ 10
Allergies-
Penicillin (rash)
PMH-
Reports general health as good. Was exercising regularly and very active until onset of
these symptoms.
Childhood illness
- chicken pox
Surgeries-
cholecystectomy, total abdominal hysterectomy
Hospitalizations-
childbirth x 2
Immunizations-
Does not receive the flu shot.
Soc Hx-
ETOH, tobacco, illicit drugs. She drinks alcohol socially, does not smoke, denies illicit
drug use. Sleeps 6 to 8 hours per night.
Divorced for 2 years, dating for 1 year. She is sexually
active with 2 partners in the last 6 months. Does not use condoms, had a BTL 10 years ago.
Family Hx-
Parents are alive in good health. She has 2 daughters in good health.
O.
PE:
VS: Height 5 feet 9 inches. Weight 150 pounds BP 126/76. T 98.0, P 72, R 12
BMI 22.2
(Normal BMI)
General: Caucasian female in no apparent distress, appears stated age. Alert, oriented and
cooperative, appears fatigued.
Skin: Skin warm, dry, and intact. Skin color is slightly jaundiced. No moles noted. No track
marks noted.
HEENT: Head normocephalic. Hair thick and distribution even throughout scalp
Eyes: .Sclera clear. Conjunctiva: icteric, PERRLA, EOMs intact
Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender
