Carolyn Cross Patient Assessment| Comprehensive Solutions| WGU C350

Carolyn Cross Patient Assessment| Comprehensive Solutions|  WGU C350

HX-40%

Physical-40%

Problem list-20%

HPI ( history of present illness)

Yearly physical

Chief  complaint:

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)

None

Bilateral fibrocystic breast changes

Allergies:    Other active problems:

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

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 Up-to-date

Vitamin E

Ibuprophen occasionally for headaches

Family Hx

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)

Preventive  Healt h:

Immu