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SUBJECTIVE:
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Chief Complaint:
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Established care. Physical and well-woman visit
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History Of Present Illness:
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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.
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Medical History:
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Sphincter of Oddi dysfunction Pancreatitis liver problems Colonoscopy in 2015 Colonoscopy in 1017, repeated in 2020 Sleep apnea Insomnia Depression Panic attacks Mood disorder
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Surgical History:
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Pancreatic surgery in 2020 Bariatric surgery in 2018 Hysterectomy in 2012 Cervix removed Breast implant silicone
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Gynecological History:
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Hysterectomy in 2012, Cervix removed, Breast implant silicone
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Family History:
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Her great grandfather; had colon cancer Father; heart failure Mother; hyperlipidemia and thyroid disease Sibling; Healthy, no health issues
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Social History:
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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.
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Smoking Status: Former Smoker
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Allergies:
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Trazodone Tramadol Cipro
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Current Medications:
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Venlafaxine 150mg ER bid alprazolam 0.25mg daily as needed Hyoscyamine 0.125mg 1 po QID Ondansetron 4mg 1 po as needed
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Review of System:
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Constitutional: Denies weight loss, fever, chills, weakness, or fatigue.
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Head: Denies headache, lightheadedness, or vertigo
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Neck: Denies pain, stiffness, or tenderness.
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Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae.
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Ears: Denies hearing loss, tinnitus, pain, vertigo, or use of an assistive hearing device.
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Nose: Denies sneezing, congestion, runny nose, discharge, obstruction, epistaxis, or sinus issues
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Mouth: Admit she needs to see the dentist for wisdom teeth removal
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Throat: Denies sore throat, hoarseness, and dysphagia.
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Cardiovascular: Denies chest pain, chest pressure, chest discomfort, palpitations, edema, or claudication
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Respiratory: Denies cough, sputum, SOB, chest congestion, Wheezing, Phlegm, or hemoptysis
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Gastrointestinal: Admit history Sphincter of Oddi dysfunction, pancreatitis, and liver problems
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Genitourinary: Denies nocturia, dysuria, incontinence, frequency, urgency, or blood in the urine
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Musculoskeletal: Admit bilateral knee pain
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Integumentary(Skin and/or Breast): Denies rash, itching, abnormal lesions or skin problems
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Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
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Psychiatric: Admit depression and panic attacks. The patient sees a psychiatrist pcp
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Endocrine: Admit pancreatitis. Denies Excessive appetite, Excessive thirst, Heat intolerance, Cold intolerance
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Hematologic/Lymphatic: Denies anemia, bleeding, or bruising. No enlarged nodes. No history of splenectomy
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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:
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Height: 64.00 in
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Weight: 183.00 lbs
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BMI: 31.41
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Blood Pressure: 114/80 mmHg
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Temperature: 97.90 F
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Pulse: 81 beats/min
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Resp. Rate: 16
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Physical Exam:
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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.
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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
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Cardiovascular: Cardiologist consult; family history of heart disease
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Chest/Breasts: History silicone breast implant
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Heart: RRR, no murmur, no gallops, or rubs
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Gastrointestinal (Abdomen): History of Pancreatitis,
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Genitourinary: no Burning/painful urination, Frequency, Urgency, Night time urination, Blood in the Urine
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Musculoskeletal: The pat is present with bilateral knee pain
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Skin: Warm and dry, rashes or abnormal lesions,
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Extremities: Full ROM without deformities; no clubbing, edema, or cyanosis
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Neurological/Psychiatric: The patient presented with depression and panic attacks. She sees a psychiatrist
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