Immunization History: Her immunizations are up to date. She received the influenza vaccine December 2017 and the Tdap in 2015. Significant Family History: Patient’s mother died five years ago from breast cancer at the age of 50. Lifestyle: Patient is a human resource manager in a large corporation. Has a bachelor’s degree. Lives in the city and commutes to work. Rents an apartment with boyfriend of two years. Diet is adequate and is well nourished. Has a great support system of friends and family. Wears seatbelt in car and while driving. She denies having a primary care provider. States, “I go to urgent care if I have something wrong with me.” Has medical insurance. Review of Systems : General: Denies fatigue, fever, chills, recent weigh gain or loss, loss of appetite, or night sweats. HEENT: Reports no changes in vision or hearing. Does not wear glasses. Last vision exam was 2 years ago. Denies double vision, blurred vision, or excessive tearing. No changes in hearing. Denies ear infections or drainage from ears. States sense of smell is intact. Denies nose bleeds, post nasal drip, or allergies. Dentition is good. Last dental exam was 6 months ago. Denies mouth ulcerations, pain, trouble chewing, or swallowing. Neck: No pain or injuries. Breasts: Reports no changes in breast. Denies pain, lesions, or masses.
Respiratory: Denies cough or 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. Never had a cardiac workup. GI: No nausea, vomiting, indigestion, or diarrhea. Denies abdominal pain. No change in bowel habits. Has history of constipation but states “bowel movements are daily.” GU: No change in urinary system. Denies dysuria, frequency, and urgency. She is heterosexual. No history of STDs. Never had HIV testing. Last Pap 11/2017. MS: Denies arthralgia/myalgia, gout, trauma, or fractures. Active and passive range of motion within normal limits. Psych: No history depression or psychiatric disorders. No complaints of insomnia. Denies suicidal/homicidal ideations. Neuro: No episodes or syncope or fainting. Denies dizziness or headaches. No change in memory. No history of seizures Integument/Heme/Lymph: She has no history of skin cancer or lesion removal. + red plaques on bilateral elbows. + itching and burning pain. She has no bleeding disorders, clotting difficulties, or history of transfusions. Denies anemia or frequent bruising. Endocrine: No endocrine symptoms. Allergic/Immunologic: No history of allergies. No immune deficiencies. OBJECTIVE DATA Physical Exam: Vital signs: B/P 114/72, right arm, sitting, regular cuff; P 80 and regular; T 98.0 orally; RR 18; non-labored; Wt: 180 lbs; Ht: 5’4; BMI 30.9 General: BB is well developed and well-nourished Caucasian female. A&O x3, no acute distress. Appears to be uncomfortable and nervous. HEENT : Head is normocephalic, atraumatic and without lesions, hair evenly distributed. PERRLA, EOMI, oronasopharynx is clear. Neck: Supple, without lesions, carotid bruits, or adenopathy. No thyroid enlargement or tenderness.
- Summer '15