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Patient’s Name: Y.M. Date of Birth: 5/7/1976 Date of Office Visit: 9/27/18
1. Age: 42 Age at first menstruation: 13 First day of last menstrual period: 9/1/18
How long does your period last? usually 7-9 days but last period/bleeding lasted 3 weeks Is your period:
2. Number of times pregnant (G): 3 Number of full--term live births (T): 3 Preterm births (P): 0 Spontaneous or
induced abortions (A): 0 Living children (L): 3 Date of last pregnancy: 2/17/15
4. HPI: Pt here to renew presecription for birth control. Last visit was in July when she was switched to Micronor from Depo.
Last Depo shot was in April 4, 2018. Pt switched from Depo to OCP Micronor because of recommendation from provider to
not be on Depo for longer than three years. Pt had been receiving Depo since the birth of her last child 2/17/15. Pt has had
3 sexual partners in her lifetime all of which were men. Last sexual intercourse 8/28/18. Menstrual cycle occurs every 28
days with 7-9 days of bleeding with the exception of the last period on 9/1/18 which lasted 3 weeks. Uses 4-5 regular pads
per day with moderate bleeding. Denies bleeding between periods, pelvic pain, irregular or excessive bleeding. Menstrual
cycle usually associated with bloating, fatigue, and cramping that is relieved by Ibuprofen. Denies history of STIs. Pt denies
any discharge, itching, or vaginal odor. Pt expresses no interest in becoming pregnant again but states her partner wants to
have more children. Pt states she preforms self breast exams monthly and denies any changes in breast tissue, breast pain,
lumps or discharge. Last mammogram in Janruary of 2018 due to right breast pain. Results of mammorgram-no
abnormalities found. Pt no longer experiencing breast pain. Denies frequency, urgency, or pain with urination. At last visit pt
had an elevated BP and was seen at San Jose clinic on Gunbarrel 7/20/18 for blood pressure no new medications were given
and told to followup in six months.
5. Past Medical History (illnesses, surgeries, hospitalizations, etc.): No previous surgeries. Only hospitalization with child
births in 2012, 2013, and 2015. No history of blood transfusions. No history of psychiatric disorders.
6. Is health maintenance up to date? (Diagnostic tests, self-exams, vaccinations, etc.): Last Pap Jan 2017- results were
abnormal cells with negative HPV, next pap due in Jan 2020. Last STD screening in 2017 with pap. HIV screening not
performed.Last mamogram Jan 2018- WNL. Patient immunizations up to date. Last Tdap Feb 2015. Last flu vaccine October
2018.
8. Have you had any of the following problems? (If YES, please explain)
Abnormal pap smear Date: Jan 2017 Treatment: repeat with
Yes No
cotesting in 3 years per ASCCP (ASC-US, negative
HPV)
Colposcopy
Yes No
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Biopsy
Yes No
Pelvic surgery Type: Date:
Yes No
Severe headaches
Yes No
Blood clots
Yes No
Problems with birth control
Yes No
Bleeding between periods
Yes No
Bleeding after periods have
Yes No
stopped
Pain with intercourse
Yes No
New or changing breast lump
Yes No
Decreased interest or
Yes No
enjoyment in sex
Change in stools, size, or texture
Yes No
Kidney infections
Yes No
Kidney stones
Yes No
Anxiety or depression
Yes No
Eating disorder
Yes No
Anemia
Yes No
Problems sleeping
Yes No
Feeling down, depressed, or
Yes No
hopeless in the past month
Little interest or pleasure in
Yes No
doing things in the past month
Been a victim of domestic
Yes No
violence
Been a victim of sexual assault
Yes No
Vaginal or pelvic infections
Yes No
History of STDs
Yes No
Anything else not mentioned
Yes No
here?
FAMILY HISTORY
2
Do you have a parent, brother or sister with a history of breast cancer?
Yes No
Do you have a parent, brother or sister with a history of female reproductive cancer (uterine,
Yes No
ovarian, or cervical)?
Additional family history information: Mother has diabetes, Brother has HTN
3
Date? Jan 2018
Was it abnormal? No, it was normal
Have you had an ovarian cyst?
Yes No
Are you sexually active? Yes No In the past, but not currently
How many partners in the last 12 months? one
How many lifetime partners? 3
Have you had your cholesterol checked?
Yes No
Do you wear your seatbelt?
Yes No
Do you feel safe where you live?
Yes No
Additional personal history or social history information: Works six days a week cleaning houses. She is not married but has
been in a relationship with her partner for ten years. Lives in an apartment and has access to running water, shelter and
electricity.
REVIEW OF SYSTEMS
If positive, mark with an X and describe further. If all negative, select ‘denies all’. If not performed, leave blank.
Constitutional: Fever Chills Fatigue Weight gain Weight loss Diet changes Denies all Notes:
Eyes: Itching Burning Vision changes Discharge Denies all Notes:
ENT: Sore throat Hoarse Nosebleed Ear pain Drainage Congestion Dental problems Denies all
Notes: Last dental visit in March 2018
Respiratory: Shortness of breath Cough Sputum Wheezing Denies all Notes:
Cardiovascular: Chest pain Palpitations Racing heart Edema Dyspnea on exertion Denies all Notes:
GI: Abdominal pain Nausea Vomiting Heartburn Dysphagia Constipation Diarrhea Melena
Hematochezia Denies all Notes:
GU: Urinary frequency Burning Itching Vaginal Discharge Pain with sex Denies all Notes:
Female: Breast pain Breast lumps Breast discharge Heavy bleeding Painful periods Irregular periods
Denies all Notes: pt states that her periods as usually 7-9 days long but this last time her bleeding lasted three weeks. Her
bleeding was moderate and used about 4-5 regular pads per day
MS: Pain Stiffness Swelling Joint pain Denies all Notes:
Hematology / Lymph: Bleeding Bruising Enlarged lymph nodes Tender lymph nodes Denies all Notes:
Endo: Excessive thirst Cold intolerance Heat intolerance Night sweats Hair loss Denies all Notes:
Skin: Rash Lesion Ulcer Pigment changes Changing moles Nail problems Denies all Notes:
Psych: Sadness Irritability Suicidal thoughts Anxiety Insomnia Sleep problems Denies all Notes:
Neuro: Headache Numbness Tingling Burning Pain Dizziness Vertigo Denies all Notes:
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Immune: Environmental allergies Sneezing Rhinorrhea Denies all Notes:
PHYSICAL EXAM
Height 64" Weight 254.2 lbs BMI 43.6 BP 132/88 T 98.4 P 72 R 19 Pain 0/10 Reason for pain:n/a
General: patient appears stated age, race and gender. Sitting upright on exam table. A&O x3, speech clear and
organized. Responds to questions appropriately. Reliable historian.
Skin/Hair/Nails: Skin and clothes clean. Skin warmand dry. Skin color brown. Normal skin turgor. No edema.
Normal female hair distribution. Nail beds pink.
ENT/Mouth: ears normal placement, ear canals without cerumen or redenss. TMs intatct without redness,
fullness or fluid. Nares patenr. No maxillary or frontal tenderness. Lips and gums pink without lesions. Teeth
white. Posterior pharynx without redenss and exudate.
CV: Heart RRR, no murmurs, no rubs, no gallops. Capillary refill <3. Radial and pedal pulses 2+.
Breasts: pendulu, Symmetrical, Contour smooth without retractions. No nipple inversion. No masses palpated.
No tenderness or discharge. Axillary lympnodes without lymphadenopathy and non tender.
Abdomen: Rounded and soft. Bowel sounds active in all four quadrants. No hepatomegaly or spleenomegaly.
Non-tender. No masses. Groin lymph nodes withou lymphadenopathy and non- tender.
Female Genitalia: external: without masses, lesions, excoriation, erythema, tenderness or discharge
MS: Upper and lower extremities with full ROM and strenth 5/5. No joint swelling, redness or tenderness. Gait
normal. No CVA tenderness
Neuro: A&O x3
5
supraclavicular,
6
6.
7.
Additional information:
Plan (diagnostics, treatments, patient education, health promotion, health maintenance, referrals, and
follow-up):
Contaception:
- ordered Pregnancy test and hgb for prolonged bleeding
- renewed prescription for Micronor
- educated pt on taking Micronor everyday within a two hour time frame, what to do if the patient misses a pill,
using condoms to protect against STDs, side effects like breast tenderness or nausea. Schedule follow up when
pt has two packs/ refills remaining on presecription to prevent running out. Bleeding should regulated within
another 3-6months with OCP if patient has any concerns or changes follow-up sooner.
Proteinuria:
- diagnositics: ordered UA showing 2+ in urine
- educated patient to Increase fluid intake to at least 2 liters of water per day, increase physical activity to 3
days a week for 30-45 minutes, eat a diet low in fats and carbs
- follow up with primary care provider for retest of urine in one month
Elevated BP:
- follow up with primary care provider in Novemeber as scheduled for six month follow up from June visit
- Educated patient to increase physcial activity to 3 days a week for 30-45 minutes, eat a diet low in fats, carbs
and sugar. Instructed pt to monitor blood pressure at home once per day using home blood pressure monitor
and bring readings to next visit with primary care provider.
Health Maintainence:
- Mammogram: pt has requested to repeart mamogram in Janruary 2019
- Next Pap in Jan 2020 with co testing per ASCCP guidelines
- Preform monthly breast exams preferrably after menstural cycle when breast tissue least effected by
estrogen.
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- HIV and STD screening- pt declined today but recommened to do at next visit with STD testing at least yearly.
- Return for annual well women exam yearly.
- Pt has elevated BMI and should increase physical activity and eat a healthy diet to encourage weight loss
- Will discuss advanced directive at next visit.
References:
Carroll, M. F., & Temte, J. L. (2000, September 15). Proteinuria in Adults: A Diagnostic Approach. Retrieved from
https://www.aafp.org/afp/2000/0915/p1333.html
Hawkins, J. W., Roberto-Nichols, D. M., & Stanley-Haney, J. L. (2016). Guidelines for nurse practitioners in gynecologic
settings (11th ed.). New York, NY: Springer Publishing Company, LLC.
Schuiling, K., & Likis, F. E. (2011). Womens gynecological health (3rd ed.). Sudbury: Jones & Bartlett Learning.