Patient name: M.G. 40 years old
Visit Type: New patient. Woman well-check examination
Location:Family Health Clinic
Date of Visit: 2/2/2021
Chief Complaint: "I came today for my annual well-woman examination."
History of Present Illness: M.G. is a 40-year-old Caucasian woman with no significant past medical history. She denies any complaints, and she feels she is in a good state of health. She explains it has been over 2 years since a doctor last saw her, and she is overdue for an annual physical examination.
Past Medical History: Mrs. M.G. states the onset of puberty began around age 12 years old, which initially was marked by breast development and menarche at 12 ½. She says her periods were regular up until she was about 22 years old. The irregularities in her menstrual cycle were marked by some skipped months, heavy menstrual bleeding and dysmenorrhea. She was prescribed birth control pills to help with her symptoms. She explains she was 22 years old when she had an abnormal pap smear. She followed through with a tissue biopsy that showed endocervical cell changes. After, she decided to have a colposcopy with the removal of the abnormal cells. She states her doctors recommended annual pap smear screening, which she has had for the last years and all of them have been normal. Her past medical history is significant for gestational diabetes in 2019. She explains her gynecologist referred her to a perinatal specialist who put her on glyburide 5 mg daily in her third trimester. She has been married for 6 years and she is sexually active with her husband. She has two children, and both were vaginal birth delivered with no complications. She says she has an IUD (Mirena) placed in 2020 after her son's birth, and her periods have stopped ever since.
- Colposcopy in 2003
- Sulfa (hives and itchy throat)
- Multivitamin 1 tab daily
- Herbal tea at nighttime to help with sleep
Td booster: 10/3/2020
Maternal Grandmother: age 79 y/,. Hx of HTN, DM, hyperlipidemia, osteoporosis
Maternal Grandfather: deceased age 75 y/o from PE. Hx of dementia, alcohol abuse,
Paternal Grandmother: deceased age 82 from unknown cause.
Paternal Grandfather: deceased age 60 from unknown cause.
Mother: age 60 y/o. DM
Father: age 60 y/o. DM, HTN, MI with CABG, hyperlipidemia,
Brother: age 42 y/o. Obesity, hyperlipidemia
Sister: age 25 y/o. Healthy
Daughter: 4 y/o. Healthy
Son: 6 months old. Healthy
Social History: Mrs. M.G. is a pleasant 40-year-old woman born and raised in Phoenix, Arizona. She lives in a one-story family house with her husband and her two children. She states her economic status is middle class and she has access to health care through privately owned insurance. M.G. works as a nurse at a local hospital during graveyard shift. She says she tries to balance her diet by eating a variety of healthy food; however, she says she never has time to cook a healthy meal. M.G.'s dietary habits consist of skipping breakfast in the morning, having pizza or a cheeseburger for lunch, and fast food for dinner right before work. She explains she drinks five cans of diet coke while working, which seems to help keep her awake. She says she maybe has a glass or two of water in a day. She denies smoking or the use of illicit drugs. She occasionally has a drink containing alcohol once a week on her days off. She explains she doesn't have any time for physical activity because she is always busy with the kids. She is Christian, and she enjoys going to church on Sundays with her family.
Risk Factors: Family history of DM, poor diet intake, physical inactivity, overweight/obesity, diabetes, hyperlipidemia, heart disease, and metabolic syndrome.
Review of System:
General: (-) fevers, (-) chills, (-) recent illness, (-) loss of appetite
Neurologic: (-) seizures, (-) tremors, (-) memory loss (-) gait problems
HEENT: (-) head pain, (-) headaches
Eyes: (-) blurry vision, (-) double vision, (-) itching eyes, (-) watering eyes, (-) eye pain, last eye exam:2/27/2020
Ears: (-) problems with hearing, (-) ear pain, (-) ringing in the ears (-) drainage from ears
Nose: (-) runny nose, (-) problems with sense of smell, (-) problems with airflow through nares
(-) bloody nose, (-) sores in the nose, (-) snoring
Mouth/Throat: (-) sore throat, (-) problems with swallowing, (-) oral lesions, (-) tooth pain, (-) problems with chewing or swallowing, (-) loose teeth, last dental exam: 3/26/2019
Cardiovascular: (-) chest pain, (-) SOB with or without exertion, (-) racing heart, (-) irregular heartbeat, (-) swelling of feet or legs, (-) pain in legs when walking
Pulmonary: (-) cough, (-) wheezing, (-) sputum production
GI: (-) blood in stool, (-) constipation, (-) diarrhea, (-) abdominal pain (-) nausea or vomiting (-) heartburn, (-) change in bowel habits
GU: (-) pain with urination, (-) frequent urination, (-) urinary urgency (-) blood in urine, (-) cloudy or foul-smelling urine,
GYN: (-) irregular menses, (-) bleeding problems, (-) premenstrual symptoms,
M/S: (-) pain or swelling in joints, (-) problems with ROM (-) muscle pain
Dermatologic/Breast: (-) rashes, (-) lesions, (-) open wounds/sores, (-) changes to nevi, (-) breast changes
Psychiatric: (-) feeling depressed (-) feeling anxious, (-) suicidal thoughts, (+) insomnia
Hematologic: (-) easy bruising, (-) abnormal bleeding
Endocrine: (-) feeling abnormally hot/cold, (-) hair loss, (+) weight loss/ gain
Allergic/Immunologic: (-) frequent infections, (-) fevers, (-) hay fever symptoms, itching
Weight: 81.8 Kg Height: 5'5" BMI: 30 (Obesity)
Waist circumference: 36 inches
O2: 98 on R/A
- General: Patient is sitting on the examination table, posture upright, shows no signs of distress, A& O x 3. Hygiene clean, well-groomed, and no malodors. Appears older than stated age, well-nourished, and hydrated. She is attentive and her mood and affect is pleasant.
- Head: Skull is normocephalic, atraumatic to palpation. There is thinning of the hair with some hair loss in in the frontal area. Scalp is free of dandruff or nevi, no lesions noted.
- Eyes: Pupils are 3 mm constriction to 2 mm, PERRLA, EOM intact, no nystagmus noted. Red reflex present. Fundoscopic examination with retina and vessels visible and no abnormalities, optic disc and cup ratio 1/3 ratio, maculae and fovea visible with light reflex. Visual acuity 20/20 with corrective glasses. No eyelids swelling, erythema or discharge.
- ENT: External ear canal free of obstruction or tenderness to pulling test. TM with gray/pearly color appearance, the inner ear bones: the incus and the malleolus visible, along with the cone of light. Hearing test passed to both ears to whispered test. Nose: Symmetrical, patent, no nasal flaring, discharge or obstruction. Mouth: Wisdom teeth missing; mucous membrane moist; tongue symmetrical and no lesions noted, tonsils grade +1. Neck: Trachea at midline; thyroid gland palpable with no lobes or goiter. No tonsillar, anterior and posterior cervical lymphadenopathy noted to palpation.
- Neurological: Oriented to time, place and person, follow commands and oriented to surroundings. Romberg test negative and performed heel-to-chin test without any problems
- Cardiovascular: Chest symmetrical, no heaves or lifts noted. Negative JVD; carotid arteries +2 to palpation and without bruit. PMI palpable at the 5th intercostal space. Heart sounds S1 and S2 auscultated with normal intensity and rhythm, no murmurs or extra heart sounds. No edema to bilateral lower extremities and warm to touch.
- Respiratory: Chest symmetrical without any tenderness to palpations. Chest expansion symmetrical with 2/1 AP diameter. Lungs sounds are clear to bilateral upper and lower lobes.
- GI:Abdomen is flabby and soft to palpation without any tenderness. No deformities, scar, masses or pulsations are noted. Spleen and kidneys are non-palpable. Bowel sounds are present to all 4 quadrants and normoactive.
- Musculoskeletal: Upper and lower extremities equal and symmetrical. No erythema, joint swelling, or deformities noted. Active ROM and muscle strength is 5/5 to bilateral upper and lower extremities.
- Dermatologic/Breast: Normal for ethnicity, pink and warm to touch. Nails beds are pink and capillary refill less < 3 sec. Breast are symmetrical, soft to palpation without any lesion, nodules, nevi or masses. Pectoral, subscapular, lateral, supraclavicular and infraclavicular lymph nodes palpable and with no enlargement.
- Genital: External genital without lesions, erythema or nodules. Uterus anterior, cervical os at midline with no lesion or discharger. Vaginal wall pink without ulceration, nodules, masses or discharge. Bimanual examination with no cervical motion tenderness, pain or tenderness.
- Psychiatric: Pleasant, cooperative and attentive. Participates in own care and is able to demonstrate appropriate interaction with the provider. Speech is clear and coherent. A&O x 3 and memory is intact.
- Pap smear with HPV co-testing: 8/20/2017- normal pap smear, no HPV detected