10 immunizations patient states she receives a yearly

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10. Immunizations: Patient states she receives a yearly flu shot. INFLUENZA dosage 0.5ml (10/08/2018, 11/15/2017, 10/12/2016). PNEUMOCOCCAL (10/12/2016) 11. Exercise and Leisure: Patient reports that she uses a treadmill for 30 minutes on Mondays and Saturdays. 12. Sleep: Patient reports she sleeps approximately 4-5 hours a night. She reports she mostly goes to be at 11 pm every night but sometimes experience insomnia; hence, she utilizes her Trazodone when struggles to sleep. She is usually up by 5 am. 13. Diet: Patient reports she drinks Dunkin Donuts decaf coffee every morning on her way to work. Dinner 9/25/2019: “mashed potatoes, gravy, and fish.” Breakfast 9/25/2019: “Dunkin Donuts decaf and sausage, egg & cheese sandwich.” Lunch 9/25/2019: “Chicken Caesar Salad.” Family History: Patient reports that her 62-year-old mother is alive and has a history of hypertension, hypothyroidism, anxiety disorder and obesity. Patient father is 65 years old and alive with a history of major depressive disorder, colon cancer, hypertension, type II diabetes, hyperlipidemia and heart failure. Patient reports that both maternal and paternal grandmothers died from heart attack. Patient reports paternal grandfather is still alive; however, maternal grandfather passed away when she was 10 years old with unknown cause. Patient has one brother who is alive with cardiovascular issues. Patient has two children; 7-year-old daughter and 9-year-old son.
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Page 3 of 6 Social History: Patient reports she has been married for 10 years, and she is in a monogamous relationship. She is sexually active with one partner and denies the use of condom or contraceptives. She denies any history of STD or risk factors for HIV. Patient denies the use of any recreational drug use. Patient reports she spend more time with her family and visits her grandfather who is at a nursing home with her two children every two weeks. Patient works as a Computer Engineer in Boston MA. Erikson: Intimacy vs. Isolation. Patient state she is happy with her current close and loving relationship with her husband for the past 10 years and has been characterized by honesty. Patient believes that her relationship with her husband and family has deepened over the years. Review of Systems: General: Patient denies having chills. Denies any sudden weight loss or gain. Denies having any unexplained bruising or bleeding. Reports occasional insomnia. Head and Neck: Denies any head injuries or headaches. Denies any pain, swelling, or stiffness. Eyes: Denies the need for corrective lenses. Denies any complications of tearing, burning, or crusting. Ears: Denies any ear pain or discharge. Nose and Sinuses: Denies any sinus complications or epistaxis. Mouth and Throat: Denies sore throat. Denies any bleeding or swelling of the gums.
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  • Fall '19
  •  Essential, Date of patient encounter

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