Carolyn Cross
41 y.o. F
5’3”
155 lb
CC: well-woman evaluation
Which of the following topics may be included in the well-woman evaluation of females age 40
– 64 years?
• Reproductive health
• General medical status and current impact of past medical history
• Psychosocial ...
Which of the following topics may be included in the well-woman evaluation of females age 40
– 64 years?
• Reproductive health
• General medical status and current impact of past medical history
• Psychosocial and occupational concerns
• Fitness and nutrition
• Risk management: disease, lifestyle, habits, environment
• Immunization status
How can I help you today? – wellness visit; risks for breast cancer; mother 63 and 1st cousin mothers
side dx with breast cancer; wants to know if it increases her risk and by how much Do you have any
other symptoms or concerns we should discuss? – physical exam, nothing more
Do you have pain anywhere? If so, where? – no, nothing unusual for me
PMHx
Can you tell me about any current or past medical problems you have had? Any new
medical issues or diagnoses since your last visit? – cousin and mother Do you have a
history of recent or current infectious disease? – no
Have you had chicken pox, mumps, measles, or rheumatic fever? – no Do you
have high blood pressure? – no
Do you have high cholesterol? – no
Have you ever had hormone replacement therapy? – no
Have you had any recent blood or lab tests? What were the results? – no
Any previous medical, surgical or dental procedures? – normal deliveries, tubal ligation, dental procedures,
regular teeth cleanings
Have you had any hospitalizations? – deliveries
Have you had any significant traumatic injuries or accidents? – no What
childhood illnesses have you had? – coughs, colds, tummy aches
Do you have any allergies, such as medications, food, and/or latex, for example? – no Are you
taking any prescription medications? – in chart
Are you taking any OTC medications? – Vitamin E and ibuprofen
When was your last physical? – a year or so ago
Are you immunizations up to date? Yes
Have you had a flu shot? Yes
Have you had a pneumovax injection? – no
, Have you had your TDAP? – why do I need to know Have
you recently traveled? Where did you go? – no At what age
did your periods begin? – age 10.5
How regular are your periods? – regular like every 25-26 days with no bleeding between When did your
last period begin? – 2 weeks ago
Do you have breast fullness or tenderness a few days before the start of your period? – yes What other
symptoms do you have with your period? (Abdominal pain, headache, bloating, etc.) – none
How many live births have you had? – 2 children, 2 pregnancies
Were there any complications when you gave birth to your child? – no When
and what were the result of your GYN exam? – around 3 yrs ago Have you
ever had a pap smear? – yes, always normal
Do you perform breast self examination? – yes
Tell me about the health of your grandparents, parents, and children. – mom 63 diagnosed with breast ca,
1st cousin 44 mother side breast ca – both had lumpectomy and receiving radiation; father has HTN and
Hyperlipidemia; no sisters; brothers are healthy
Are there any diseases that run in your family? – now yes
Do you know of any genetic diseases that are found in your family? – no
Social Hx
Where were you born and where did you grow up? – here What is
your ancestry? – Hispanic descent
Where and with whom are you living? – husband and boys Do
your religious or cultural beliefs … ? – no
What is your educational background? – why do I need to know What
is your highest level/grade in school? – why am I asking
What is your native language? How well do you understand English? – understands Within your
list of responsibilities … - whey do I need to know
Tell me about your work. – middle-school learning specialist
Do you drink alcohol? If so, what do you drink and how many drinks per day? – glass of wine with
dinner each night
Do you use any recreational drugs? If so, what? – none
Do you now or have you ever smoked or chewed tobacco? – no
Can you tell me about your diet, what do you normally eat? – tries to provide healthy meals; eats fast food
at least once a week; pizza once a week; traditional Hispanic diet; cookies at night; 1% milk
Do you drink caffeinated beverages or eat chocolate? – no How is
your appetite? Any recent changes? – fine, no changes
Tell me about your daily exercise or sports you play. – housework and gardening, no sports Any new
exercise or activities? – no
On average, how many hours per night do you sleep? – 6-8 hrs Do
you have adequate housing? – yes
Do you have any children? Spouse? Significant other? – husband for 14 yrs, 2 boys, extended family
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 THEEXCELLENCELIBRARY. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $18.99. You're not tied to anything after your purchase.
