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
...
Problem list-20%
HPI ( histo ry of pre s en t il ln e ss )
Chief complaint:
Yearly physical
HPI:
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has
no complaints.
.
PMH ( p re vio us medi ca l h is to ry )
A lle r gie s :
None
Ot her a ct ive pr o b lems :
Bilateral fibrocystic breast changes
Med ica l , s ur gica l, o b st et r ic, 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
Pap smears in the past are So cial Hx
negative Diet: Tries to eat a Ethnicity: Hispanic-
well-balanced diet American
Exercise: Walks to and from the train 5 days a week; weekend Occ
upa
gardening Up-to-date tion:
Mid
dle-
Vitamin E sch
Ibuprophen occasionally for headaches ool
lear
ning
spe
Family Hx
ciali
Father: Hypertension,
st
hyperlipidemia Mother: Hx of
Mari
type 2 diabetes Sisters: No
tal
sisters
stat
Brothers: Healthy and very physically active
us:
Mar
ried
, x ~13 years Pr event ive Healt h:
Children: 2 sons (5ish and
7ish) Tobacco: Never
Recreational drugs: Never
Alcohol: Wine (one glass at dinner most days) I mmun i za t io n s :
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