Patient Initials: BB Age: 64 Gender: F CASEY STUDY: #2 SUBJECTIVE DATA: Chief Complaint (CC) : “I have these red spots on my chest” History of Present Illness (HPI): BB is a pleasant Caucasian female who presents to the clinic today with complaints of small red spots on her chest, abdomen, and axillae. She reports them being present for a few months but does not know the exact timeframe. She states, “I know the number of them have been increasing, and sometimes they bleed.” The lesions do not cause pain or itching. Medications: 1.) Hydrochlorothiazide 25mg po daily Allergies: No known drug allergies, no known food allergies, no known environmental allergies Past Medical History (PMH): 1.) Hypertension Past Surgical History (PSH): No past surgical history Sexual/Reproductive History: Heterosexual G3P3A0 Last pap smear 02/2017 Personal/Social History: Denies smoking. ETOH use- drinks 2 beers a day. Immunization History: Her immunizations are up to date. She received the influenza vaccine November 2017, Pneumococcal vaccine in November 2016, and Tdap 2014. Significant Family History: Patient’s mother died at age 71 from pancreatic cancer. Patient’s father died at age 80 from prostate cancer. Has 2 living brothers and 4 living sisters with no significant diseases. Lifestyle: Patient is retired x 10 years. Is divorced and lives alone. Lives in a one-story dwelling in the city that she owns. She is a college graduate and receives a pension of $40,000 annually – financially stable. Wears seatbelt in car and while driving.
She sees a medical doctor for routine care every three months. She has medical insurance. She demonstrates a health diet and eating pattern. She has a good support system at home with nearby friends and family. Review of Systems : General: Denies fatigue, fever, chills, night sweats, recent weigh gain or loss, or loss of appetite. HEENT: Reports no changes in vision or hearing. She does wear glasses while reading and driving at night. Last eye exam was six months ago. No history of glaucoma, diplopia, floaters, tearing, or photophobia. No recent hearing changes, discharge, ringing in the ears, or ear infections. Reports that sense of smell is intact and has had no changes. Denies epistaxis, nasal drainage, allergies, or sinus pressure. Denies mouth ulcerations or bleeding gums. Does not wear dentures. Last dental exam was one month ago. Denies any difficulty chewing or swallowing. Neck: No pain, injury, or history of disc disease or compression. Breasts: Reports no changes in breast. Denies pain or lumps. No abnormal mammograms. Respiratory: Denies cough and sputum. No dyspnea. Denies ever having positive PPD. CV: Denies chest pain, palpitations, edema, pain with walking, and nocturnal dyspnea. No history of murmurs. No varicosities. GI: No nausea, vomiting, indigestion, or diarrhea. Denies abdominal pain. No change in bowel habits. Has no history of constipation or ulcers.
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- Summer '15