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Health Assessment

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Constitutional symptoms: Pt states she exercises 2-3 times per week with a yoga class. She maintains a regular diet in which she tries to eat low fat for her cholesterol. She is conscious of her high cholesterol and states it has improved. Pt states overall health as good.

Eyes: Pt is myopic in which she wears glasses and contacts. She denies any changes in vision and pain.

Ears, nose, mouth, and throat (ENT): Pt states she has no changes in auditory function. Pt denies congestion. Pt denies any soreness in her throat, no hoarseness or pain noted.

Cardiovascular: Patient denies any palpitations, lightheadedness, or angina. No claudication noted. Pt denies and calf tenderness or swelling.

Respiratory: Pt denies dyspnea on exertion, cough, wheeze, and decrease exercise tolerance. Gastrointestinal: Pt denies any pain, discomfort, nausea, vomiting, and diarrhea. Pt states she has a bowel movement daily, last one this morning, moderate in size and formed. Denies any changes in stool character. Pt denies s/s of GERD.

Genitourinary: Pt states she is continent. Denies pain with urination. States that urine is clear, yellow. Denies frequency, urgency, and hematuria.

Musculoskeletal: Pt states she does have back pain that has worsened over the past two weeks. Denies trauma, pain is location between clavicles on thoracic spine. Pain is localized and does not radiate. Pain is made worse with physical activity. With activity pain can be a level 6 out of 10. Quality of pain is described as dull constant aching. Pain is managed by NSAIDs when needed and rest. Patient is to see her PCP on 2/6/14.

Integument: Denies rash, wounds, pruritis, lesions, and changes in skin, hair, and nails.

Neurological: Pt denies headache, changes in cognition, memory. Pt states sensation is present in all extremities.

Psychiatric: Pt denies any psychiatric history or suicide ideations.

Endocrine: Pt has Polycystic Ovary Syndrome diagnosed in 2007, which is medically managed by her endocrinologist. Pt states she has irregular periods. When she does have a menstrual cycle it is often long and menstrual flow is quite heavy. Cycles tend to be quite painful. Pain is generalized to the lower abdomen and typically an 8/10. Pain is managed by heating pad, rest, and NSAIDs. She is currently not in pain and her last menstrual period was 3 months ago. Her last GYN visit was last year.?????????

Hematologic/lymphatic: Denies bruising.

Allergic/immunologic: NKA

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