Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP Vaginal discharge; itching; sores; lumps Menopause; hot flashes; post- menopausal bleeding; Fibroid Tumors since 2018 Small tumors cause heavy bleeding during menses Prescribed medication for preventive anemia but refuses to take. Peripheral Vascular Claudication; leg cramps; varicose veins; hx of blood clots NEGATIVE Musculo- skeletal Muscle or joint pain; joint stiffness NEGATIVE Neuro Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements NEGATIVE Heme Hx of anemia; easy bruising or bleeding; blood transfusions NEGATIVE Endo Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size NEGATIVE Psych Nervousness/anxiety; depression; memory changes; suicide attempts NEGATIVE 4
General Findings and Physical Exam General Observations Does patient appear to be their stated age? yes Level of consciousness Alert and orient x4 Skin color Even, smooth, brown skinned Nutritional status Consumes 3 meals per day Posture and position Gait steady Obvious physical deformities None observed Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Gait steady, ambulated in room without difficulty. Has no assistive devices. Upper and lower extremities move with no pain. No involuntary movements noted during the assessment. Facial expression Smiling at times during the initial assessment Mood and affect Calm Speech: articulation, pattern, content and appropriate, native language Speech articulate and appropriate Hearing Able to hear soft whisper. Whispered into patient’s ear and asked to repeat number she heard. Personal hygiene No odor detected during the interview Measurements and Vital Signs Weight 188 Height 5 ft. 6 in BMI 30.1 Radial pulse: rate rhythm 62 bounding, regular Respirations: 20 quiet, unlabored, even 5
rate depth Blood pressure (indicate if sitting or lying) 100/56 sitting, left arm Temperature (if indicated) Skin warm to touch Pain assessment No complaint of pain during the assessment or daily. Skin Hands and nails No ridges, smooth nail bed, hands warm to touch No rash, no lesion, palpated skin and inspected skin Color and pigmentation Normal for ethnic group. Skin was inspected. Temperature Skin was palpated warm to touch Moisture Skin was palpated to detect is moisture was present Texture skin was palpated and inspected, Soft and smooth Turgor Skin was palpated. Turgor was firm. Presence of lesions? Skin was inspected. No skin lesions note. Head and Face Scalp Hair Cranium No depressed areas, no lesion, no nevi, no parasites No surgical sites noted in the scalp or cranium The scalp was inspected and palpated. Hair was distributed throughout scalp.
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