| SUBJECTIVE: |
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| Chief Complaint: |
Established care. Physical and well-woman visit |
| History Of Present Illness: |
The patient is a 41-year-old female who presented for physical and well-woman care. The patient is new in the area, she moves from Michigan state. She has a history of hysterectomy in 2012, Cervix removed Breast implant silicone. Has a mood disorder and is experiencing insomnia, multiple surgery, and digestive issues. The patient was very obese, for which she underwent bariatric surgery. The patient c/o BLE cramping and BUE pain. She needs a psychiatrist in the area. Will need a cardiologist to consult due to a family history of heart disease? Multiple chronic health issues are controlled with medications. Rates bilateral knee pain as 4/10. |
| Medical History: |
Sphincter of Oddi dysfunction Pancreatitis liver problems Colonoscopy in 2015 Colonoscopy in 1017, repeated in 2020 Sleep apnea Insomnia Depression Panic attacks Mood disorder |
| Surgical History: |
Pancreatic surgery in 2020 Bariatric surgery in 2018 Hysterectomy in 2012 Cervix removed Breast implant silicone |
| Gynecological History: |
Hysterectomy in 2012, Cervix removed, Breast implant silicone |
| Family History: |
Her great grandfather; had colon cancer Father; heart failure Mother; hyperlipidemia and thyroid disease Sibling; Healthy, no health issues |
| Social History: |
| She drinks I cup of coffee a day a history of 20 years pack smoker-she quit smoking one month ago and started Chantix 1 month ago. The patient denies alcohol intake and the use of illicit drugs. She has used glasses since 2022 and sees an eye doctor. Will need a dentist referral for wisdom teeth removal. She eats 3-5 meals on the go. She sees a psychiatrist in Azle, texas. |
| Smoking Status: Former Smoker |
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| Allergies: |
Trazodone Tramadol Cipro |
| Current Medications: |
Venlafaxine 150mg ER bid alprazolam 0.25mg daily as needed Hyoscyamine 0.125mg 1 po QID Ondansetron 4mg 1 po as needed |
| Review of System: |
| Constitutional: Denies weight loss, fever, chills, weakness, or fatigue. |
| Head: Denies headache, lightheadedness, or vertigo |
| Neck: Denies pain, stiffness, or tenderness. |
| Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. |
| Ears: Denies hearing loss, tinnitus, pain, vertigo, or use of an assistive hearing device. |
| Nose: Denies sneezing, congestion, runny nose, discharge, obstruction, epistaxis, or sinus issues |
| Mouth: Admit she needs to see the dentist for wisdom teeth removal |
| Throat: Denies sore throat, hoarseness, and dysphagia. |
| Cardiovascular: Denies chest pain, chest pressure, chest discomfort, palpitations, edema, or claudication |
| Respiratory: Denies cough, sputum, SOB, chest congestion, Wheezing, Phlegm, or hemoptysis |
| Gastrointestinal: Admit history Sphincter of Oddi dysfunction, pancreatitis, and liver problems |
| Genitourinary: Denies nocturia, dysuria, incontinence, frequency, urgency, or blood in the urine |
| Musculoskeletal: Admit bilateral knee pain |
| Integumentary (Skin and/or Breast): Denies rash, itching, abnormal lesions or skin problems |
| Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. |
| Psychiatric: Admit depression and panic attacks. The patient sees a psychiatrist pcp |
| Endocrine: Admit pancreatitis. Denies Excessive appetite, Excessive thirst, Heat intolerance, Cold intolerance |
| Hematologic/Lymphatic: Denies anemia, bleeding, or bruising. No enlarged nodes. No history of splenectomy |
| Allergic/Immunologic: Denies history of asthma, hives, eczema, itching, nasal congestion, rash, rhinitis, environment |
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| OBJECTIVE: |
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| Vital Signs: |
| Height: 64.00 in |
| Weight: 183.00 lbs |
| BMI: 31.41 |
| Blood Pressure: 114/80 mmHg |
| Temperature: 97.90 F |
| Pulse: 81 beats/min |
| Resp. Rate: 16 |
|
| Physical Exam: |
| Constitutional: A 41-year-old well-developed, well-nourished, female who is alert, oriented, and cooperative. She is a good historian and answers questions readily and appropriately. She appears to be in no acute distress. |
| Ears, Nose, Mouth, and Throat: Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal, started using since 2022, ear: EAC’s clear, TM’s normal, Throat: clear, no exudates, Neck: supple, adenopathy, no thyromegaly, no carotid bruits |
| Cardiovascular: Cardiologist consult; family history of heart disease |
| Chest/Breasts: History silicone breast implant |
| Heart: RRR, no murmur, no gallops, or rubs |
| Gastrointestinal (Abdomen): History of Pancreatitis, |
| Genitourinary: no Burning/painful urination, Frequency, Urgency, Night time urination, Blood in the Urine |
| Musculoskeletal: The pat is present with bilateral knee pain |
| Skin: Warm and dry, rashes or abnormal lesions, |
| Extremities: Full ROM without deformities; no clubbing, edema, or cyanosis |
| Neurological/Psychiatric: The patient presented with depression and panic attacks. She sees a psychiatrist |
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