Breasts Lumps; pain; discomfort; nipple discharge No lump in breasts or nipple discharge. Denies pain or discomfort. With history of BRCA 2 will recommend closer follow up with GYN to follow guideline for screenings. Pulmonar y Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains Denies cough. No wheezes, lungs clear bilaterally both anterior and posterior, denies pain Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema Denies chest pain, palpitations, or shortness of breath or swelling. No edema. G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; Denies appetite changes, nausea, or changes in bowels 4
constipation; diarrhea; food intolerance Urinary Frequency; nocturia; urgency; dysuria; hematuria; incontinence MALES : caliber of urinary stream; hesitancy; dribbling Denies frequency, urgency, or pain on urination G/U (General) Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure Uses timing method of birth control, married in monogamous relationship. Denies exposure to std of any kind, not high risk for hiv or hepatitis Male G/U Discharge from or sores on penis; testicular pain/masses Put N/A here Female G/U 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; Menarche at age 12, denies PMS, irregular bleeding, LMP 9/21/2019, 30 day cycles, no pain with intercourse Peripheral Vascular Claudication; leg cramps; varicose veins; hx of blood clots No history of blood clots, denies leg cramps, no varicosities, no history of clotting disorders Musculo- skeletal Muscle or joint pain; joint stiffness Denies muscle or joint pain or stiffness Neuro Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements Denies fainting, numbness, tingling, tremors Heme Hx of anemia; easy bruising or bleeding; blood transfusions No history of anemia, 5
bruising or transfusions Endo Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size Denies heat or cold intolerance, excessive sweating, thirst, hunger, or urination. No change in glove or shoe size. Psych Nervousness/anxiety; depression; memory changes; suicide attempts History of PPD, unmedicated. No suicide attempts. Denies anxiety or current depression. General Findings and Physical Exam General Observations Does patient appear to be their stated age? Yes Level of consciousness Alert and oriented x4 Skin color Appropriate for ethnicity Nutritional status Well nourished Posture and position Upright and appropriate Obvious physical deformities No obvious physical deformities Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Steady gait, no use of assistive devices Facial expression Smiling, appropriate expressions Mood and affect Pleasant appropriate affect 6
Speech: articulation, pattern, content and
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- Spring '16
- Shelley Ashby
- HPI, Nipple discharge