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WGU C350 - Carolyn Cross Assessment (with medical history)
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WGU C350 - Carolyn Cross Assessment (with medical history)
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WGU C350 - Carolyn Cross Assessment (with medical history)HX-40%
Physical-40%
Problem list-20%
HPI (history of present illness)
Chief complaint:
Yearly physical
HPI:
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has no
complaints.
.
PMH (previous medical history)
A l l e rg i e s :
None
O t h e r a c t i v e p ro b l e m s :
Bilateral fibrocystic breast changes
M e d i c a l , s u rg 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 :
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
P re v e n t i v e H e a l t h :
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
Fa m i l y H x
Father: Hypertension, hyperlipidemia
Mother: Hx of type 2 diabetes
Sisters: No sisters
Brothers: Healthy and very physically active
Social 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)
This study source was downloaded by 100000838928381 from CourseHero.com on 07-05-2022 14:18:33 GMT -05:00
https://www.coursehero.com/file/67142685/Carolyn-Cross-assessment-minedocx/
, ROS (review of systems)
General/ Constitutional:
Normal energy level
No sleep concerns
Weight stable
S k i n / B re a s t :
Negative except for lumpy breasts
HEENT & Neck:
Negative
C a rd i o v a s c u l a r:
Negative
Re s p i r a t o r y:
Negative
A b d o m e n / G a s t ro 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 ke l e t a l :
Negative
N e u ro l o g i c a l :
Negative
Allergic/Immunologic:
Negative
Ly m p h a t i c / E n d o c r i n e :
Negative
Hematologic:
Negative
Psychological:
Negative
Vitals
Temp : 98.6 F
Puls e : 72, rhythm: regular
BP : left: 130/72
Res pira ti on
: 14, effort: unlabored
Physical Exam
We i g h t :
148.0 pounds
S k i n / B re a s t :
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 through both breasts; no suspicious, discrete palpable lesions
Slight tenderness to exam reported
This study source was downloaded by 100000838928381 from CourseHero.com on 07-05-2022 14:18:33 GMT -05:00
https://www.coursehero.com/file/67142685/Carolyn-Cross-assessment-minedocx/
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