Denies any hearing loss, ear pain, or ear drainage. Reports having problems with sneezing only around cats and dust. Denies any congestion, runny nose, sore throa,tchanges in taste, difficulty swallowing, mouth problems, tongue problems, or teeth problems. Last dental exam was a few years ago. Skin: Miss Jones has reported thatshe's noticing discoloration on her neck and stated is "looking weird". She reports dryness on her skin in her arms and her legs. She uses the lotion on her skin. Deniesany changes in her skin, rashes, lesions, family history of skin disease. Miss Jones reports having acne since middle school she treats her acne by washing her face every night. Reports having moles and hasn't noticed any changes in them. Does occasional skin self-exams. Denies any changes in her nails. Reports some excessive hair growth on her face and her chin and her belly. Cardiology: denies any problems with her heart. denies having any angina, circulatory problems, blood clots,rheumatic fever, or any heart murmurs. Family history of MI on maternal grandfather.Maternal grandmother died of stroke. Denies any edema or paplpitaions. Reports nocturia three times a night. Respiratory: has a personal history of asthma that is controlled by daily flovent inhaler and a PRN Proventil inhaler. Is not currently being
followed by a pulmonologist. Reports dyspnea when her asthma is acting up along with chest tightness. Currently there is no deficiency. Denies any current cough. Gastrointestinal: as noted above she's currently in for epigastric pain. Denies any dysphasia,nausea, vomiting, diarrhea, constipation, or recent travel. Bowel movement was last night. She reports typically going every other day to every day describes her stools as "not hard or not to soft". Denies any history of ulcers, hepatitis jaundice, appendectomies or a hernia. Denies any gas or bloating. Denies history of GERD. Genitourinary: Reports Urine as light yellow to clear in color with noodor. denies burning with urination, urinary hesitancy or hematuria. She reports an increase in urination frequency and reports that she's been drinking more water. GYN: last menstrual period was a month ago and she reports that her menstrual periods are bad she would gets cramps and bleeding that last longer than a week. Menarche was at age 11. She's a heterosexual that has had three male partners. Reports having tested for STDs during her last pap smear. Last pap smear was noted at four and a half years ago. Denies any previous pregnancies is not currently pregnant. Neurological: reports headaches during reading. Denies any dizziness, syncope or vertigo. Denies any numbness or tingling. Denies any history of seizures. Denies any bowel or bladder control changes. Musculoskeletal: denies any problems
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- Fall '15