HPI (History of present illness):
Name: Renata Chapman
Age: 42 years
Sex: F
Height: 5' 5" (165.0 cm)
Weight: 149 lb (68.0 kg) (BMI
... [Show More] 24.8)
Temperature: 98.4 F (oral)
Pulse: 72 bpm - regular
Blood pressure: 116/68 mmHg - supine/sitting
Blood pressure: 102/62 mmHg - upon standing
Respiratory rate: 16 bpm
SpO2: 98% on room air
PMH (Pervious medical history):
Allergies: None
O t h e r a c t i v e p r o b l e m s :
Right-ovarian hemorrhagic cyst (spontaneously resolved): year unknown
Chronic idiopathic pancreatitis: diagnosed in her 20s
Hypothyroidism: age at time of diagnosis not recalled
M e d i c a l , s u r g i c a l , o b s t e t r i c , h o s p i t a l i z a t i o n s :
OB/GYN: Menarche age 14; G2P2; first pregnancy at age 25 vaginal; second at age 32 C-section 7 years
ago, follow by a bilateral tubal ligation (BTL)
P r e v e n t i v e H e a l t h :
Full childhood vaccinations
Exercise: None; sedentary
Diet: Predominantly fast foods aunt junk food per patient's account
I m m u n i z a t i o n s :
Immunizations: none in the last 7 years
Completed childhood-vaccination schedule
Medications:
Levothyroxine 25 mcg one tablet daily
Pancrelipase 15000 units two tablets before each meal and snack
Oxycodone 5 mg one tablet every four hours as needed
Amitriptyline 25 mg one tablet daily
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Family History:
Mother: alive; breast cancer diagnosed at age 48 (lumpectomy, no known recurrence)
Father: alive and healthy
Siblings: none
Social History:
Occupation: Disabled due to chronic pancreatitis
Marital status: Never married; lives with her two children
Sexual history: Not sexually active for the last 5 years; negative HIV test sometime within the last 7 years
Alcohol use: Two glasses of wine a day starting at 18 years of age; none for six years
Tobacco use: Less than one pack a day from 18-20 years of age; none since
Illicit drugs: None/never
ROS (Review of System):
General/Constitutional: Negative
S k i n / B r e a s t : Negative---did not feel anything prior to mammographic finding
H E E N T & N e c k : Negative
C a r d i o v a s c u l a r : Negative
R e s p i r a t o r y : Negative
A b d o m e n / G a s t r o i n t e s t i n a l : Negative
G e n i t o u r i n a r y : Negative
M u s c u l o s k el e t a l : Negative
N e u r o l o g i c a l : Negative
A l l e r g i c / I m m u n o l o g i c : Negative
L y m p h a t i c / E n d o c r i n e : Negative
H e m a t o l o g i c : Negative
P s y c h o l o g i c a l : Negative
Vital signs:
Temp: 98.6F
Pulse: 70, rhythm: Regular
BP: Left 116/70
Respiration: 16, effort: unlabored
Physical exam:
148.0 pounds
S k i n / B r e a s t :
deferred on this follow-up visit [Show Less]