Well woman visit
Pt 41 y/o no PMH, no new medical issues, concern about risk of breast CA. Mother age 63 diagnosed with breast CA as well as mother's side 1st cousin. Pt has naturally lumpy breasts, last year's mammogram normal. Weight gain of 5lbs.
Identifies as generally healthy, no major hea...
Pt 41 y/o no PMH, no new medical issues, concern about risk of breast CA. Mother age 63 diagnosed
with breast CA as well as mother's side 1st cousin. Pt has naturally lumpy breasts, last year's
mammogram normal. Weight gain of 5lbs.
Identifies as generally healthy, no major health issues. Weight gain of 5-10lbs in last year
No complaints of neck or ear pain, or itchy scalp. No visual or hearing issues. Occasional headaches takes
Ibuprofen.
No reports of chest pain, palpitations, or chest pressure.
No SOB, wheezing, difficulty catching breath, or cough.
No n/v, constipation, diarrhea. Regular bowel movements.
No pain while urinating, incontinence, urgency or frequency.
No muscle pain, joint pain, difficulty with movements, stiffness, swelling, or cramping of joints or
muscles. No back, shoulder or hip pain.
No dizziness, fainting, numbness, tingling, tremors, seizures, or weakness.
No skin changes, new moles, or brittle nails. Pt reports naturally lumpy breasts- fibrocystic breast cysts
in both breasts. No discharge or pain in breasts.
No depression, psychotic thoughts, or anxiety.
No heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in
appetite
No bruising, bleeding gums, nose bleeds, or increased bleeding
No allergies or previous allergic reactions.
No PMH
hospitalized only for delivery of two children
all immunizations up to date
Vitamin E for breast health, Ibuprofen for occasional headaches, no prescription medications
no allergies
Pt lives with her husband and 2 young children. She works full time as a middle-school specialist
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