HX-40%Physical-40%Problem list-20%H P I ( h i s t o r y o f p r e s e n t i l l n e s s )C h i e f c o m p l a i n t :Yearly physicalH P I :Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has nocomplaints..P M H ( p r e v i o u s m e d i c a l h i s t o r y )A l l e rg i e s :NoneO t h e r a c t i v e p ro b l e m s :Bilateral fibrocystic breast changesM 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: NoneSurgical: G2P2; Bilateral tubal ligation following last delivery at age 35OB/Gyn: NSVD x two; breast fed both for 4 months; premenopausal; menses regular since age 10.5P re v e n t i v e H e a l t h :Pap smears in the past are negativeDiet: Tries to eat a well-balanced dietExercise: Walks to and from the train 5 days a week; weekend gardeningI m m u n i z a t i o n s :Up-to-dateVitamin EIbuprophen occasionally for headachesFa m i l y H xFather: Hypertension, hyperlipidemiaMother: Hx of type 2 diabetesSisters: No sistersBrothers: Healthy and very physically activeS o c i a l H xEthnicity: Hispanic-AmericanOccupation: Middle-school learning specialistMarital status: Married x ~13 yearsChildren: 2 sons (5ish and 7ish)Tobacco: NeverRecreational drugs: NeverAlcohol: Wine (one glass at dinner most days)Preview Mode
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