Exam (elaborations)
Carolyn Cross Patient Assessment| Comprehensive Solutions| WGU C350
- Course
- Institution
Carolyn Cross Patient Assessment| Comprehensive Solutions| WGU C350
[Show more]
Seller
Follow
QuizMerchant
Reviews received
Content preview
HX-40%Physical-40%
Problem list-20%
HPI ( h istor y of p re se nt illn e ss)
C hi e f c o m pl a i nt :
Yearly physical
HPI:
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has nocomplaints.
.
PMH ( p r e viou s me dic al h ist or y)
Allergies:
None
Other ac ti ve p r o b l e m s :
Bilateral fibrocystic breast changes
M e d i c a l , s u r g i c a l , o b s t e tr 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 r e ve nt i ve Healt 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 gardeningUp-to-
I m m un i z a ti o n s :
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 specialistMarital
status: Married x ~13 years
Children: 2 sons (5ish and 7ish)
Tobacco: Never
Recreational drugs: Never
Alcohol: Wine (one glass at dinner most days)
, ROS ( r evie w of sys te ms)
G e ne r a l / C o ns t i t ut i o n a l:
Normal energy level
No sleep concerns
Weight stable
S ki n /B re a st:
Negative except for lumpy breasts
HE EN T & Nec k:
Negative
Cardiovascular:
Negative
R es pi ra t or y:
Negative
Abdomen/ Gastrointestinal:
Negative
G e n i t o u r i nary:
Negative
Musculoskeletal:
Negative
Neurological:
Negative
Al l e r gi c / I m m u n o l o g i c :
Negative
L y m pha ti c/ E n d o c r i n e :
Negative
He mat ologic:
Negative
Psychological:
Negative
Vit al s
Temp: 98.6 F
Pulse: 72, rhythm: regular
BP: left: 130/72
Respiration
: 14, effort: unlabored
Ph ysic al Exam
Wei ght:
148.0 pounds
S ki 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 lesionsSlight
tenderness to exam reported
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller QuizMerchant. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $15.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
79064 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now