Carolyn Cross assessment Mine
HX-40%
Physical-40%
Problem list-20%
H P I ( h is tory o f p rese nt i l lne s s)
Chief complaint:
Yearly
... [Show More] physical
HPI:
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has no
complaints.
.
PMH ( p rev io us me d ica l h istory )
Allergies:
None
Other active problems:
Bilateral fibrocystic breast changes
Medical, surgical, obstetric, hospitalizations:
Medical: None
Surgical: G2P2; Bilateral tubal ligation following last delivery at age 35
OB/Gyn: NSVD x two; breast fed both for 4 months; premenopausal; menses regular since age 10.5
Preventive Health:
Pap smears in the past are negative
Diet: Tries to eat a well-balanced diet
Exercise: Walks to and from the train 5 days a week; weekend gardening
Immunizations:
Up-to-date
Vitamin E
Ibuprophen occasionally for headaches
Fam i ly Hx
Father: Hypertension, hyperlipidemia
Mother: Hx of type 2 diabetes
Sisters: No sisters
Brothers: Healthy and very physically active
So c ia l Hx
Ethnicity: Hispanic-American
Occupation: Middle-school learning specialist
Marital status: Married x ~13 years
Children: 2 sons (5ish and 7ish)
Tobacco: Never
Recreational drugs: Never
Alcohol: Wine (one glass at dinner most days)
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ROS (rev iew o f sys tems )
General/ Constitutional:
Normal energy level
No sleep concerns
Weight stable
Skin/Breast:
Negative except for lumpy breasts
HEENT & Neck:
Negative
Cardiovascular:
Negative
Respiratory:
Negative
Abdomen/ Gastrointestinal:
Negative
Genitourinary:
Negative
Musculoskeletal:
Negative
Neurological:
Negative
Allergic/Immunologic:
Negative
Lymphatic/Endocrine:
Negative
Hematologic:
Negative
Psychological:
Negative
V ita ls
Temp: 98.6 F
Pulse: 72, rhythm: regular
BP: left: 130/72
Respiration
: 14, effort: unlabored
Phys ica l Exam
Weight:
148.0 pounds
Skin/Breast:
No pallor, jaundice, ecchymoses, or rash
Normal, symmetrical breast contour
No visible skin or nipple abnormalities
No spontaneous or expressed nipple discharge or blood
Irregular "lumpy bumpy" consistency [Show Less]