Immunization History: She receives influenza vaccine every December. She was received pneumonia vaccine last September 2013. She thinks she had received tetanus vaccine 10 years ago. Significant Family History: She has 3 brothers and 5 sisters. She is the youngest. She claims being a “Menopause baby”. One brother died of colon cancer August 2014. Three of her sisters have DMII, 1 brother acquired hepatitis C. Her father died of heart attack at the age of 73, and her mother died of complications from old age at 95. Two of her sisters had history of hyperthyroidism. 3
SKIN CONDITIONS Lifestyle: She practices Catholicism, and goes to church everyday. She got into 2 nd year college but was unable to finish because of financial difficulties. She rents a two- bedroom located in the second floor of her apartment building, and she is living by herself. She spends her leisure time with her friends from church at I-hop restaurant near her church every Wednesday morning. On most weekends, she visits her sisters and sometimes spends overnight with them. She works full-time as a manager at Target from Mondays thru Fridays, 2pm -10 pm. She earns $40,000 a year and carries private health insurance. Review of Systems: General: Ms. Sonna claims she is unable to sleep at night lately due to stress from work. Although she keeps her screenings and doctor’s appointment up-to-date, she sometimes “slacks off” with the diet recommendation and unable to keep up with an exercise regimen. She claims that her skin condition makes her feel self-conscious at all times, and that added more stress on her. She admits having a sedentary lifestyle from not getting any exercise. She worries about gaining weight from the past 4 months. HEENT: She wears eyeglasses when reading and sunglasses when driving in the morning. She claims getting eye exams every year. She has a small cataract on her right eye but her opthalmologist does not recommend surgical removal at this time. She denies retinopathy. She claimed having difficulty hearing at times but says she does not need hearing aids at this time. She reported not having any ear infection. She reported having an intact sense of smell and denies any sinus infection or any nasal problems, although she claims having seasonal allergies especially during spring season. She wears partial upper denture, and she claims having some teeth treated and had fillings. She visits her dentist every 6 months, her last dental exam was last August 8, 2018. She denies gum bleedings, mouth ulceration or oral infections. She does not have any problems in swallowing nor chewing food. Neck: She denies any pain, injury, or trauma in the past. She does not feeling any lump nor mass in her neck area. She swallows well without difficulty.
- Summer '15