Carolyn Cross Assessment Mine Pracitce Exam with Answers (125 Solved Questions)
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HX-40%
Physical-40%
Problem list-20%
H P I ( h i s t o r y o f p r e s e n t i l l n e s s )
C h i e f c o m p l a i n t :
Yearly physical
H P I :
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has no
complaints.
.
P M H ( p r e v i o u s m e d i c a l h i s t o r y )
A l l e rg i e s :
None
O t h e r a c t i v e p ro b l e m s :
Bilateral fibrocystic breast changes
M e d i c a l , s u rg i c a l , o b s t e t r i c , h o s p i t a l i z a t i o n s :
Medical: None
Surgical: G2P2; Bilateral tubal ligation following last delivery at age 35
OB/Gyn: NSVD x two; breast fed both for 4 months; premenopausal; menses regular since age 10.5
P re v e n t i v e H e a l t h :
Pap smears in the past are negative
Diet: Tries to eat a well-balanced diet
Exercise: Walks to and from the train 5 days a week; weekend gardening
I m m u n i z a t i o n s :
Up-to-date
Vitamin E
Ibuprophen occasionally for headaches
Fa m i l y H x
Father: Hypertension, hyperlipidemia
Mother: Hx of type 2 diabetes
Sisters: No sisters
Brothers: Healthy and very physically active
S o c i a l H x
Ethnicity: Hispanic-American
Occupation: Middle-school learning specialist
Marital status: Married x ~13 years
Children: 2 sons (5ish and 7ish)
Tobacco: Never
Recreational drugs: Never
Alcohol: Wine (one glass at dinner most days)
Physical-40%
Problem list-20%
H P I ( h i s t o r y o f p r e s e n t i l l n e s s )
C h i e f c o m p l a i n t :
Yearly physical
H P I :
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has no
complaints.
.
P M H ( p r e v i o u s m e d i c a l h i s t o r y )
A l l e rg i e s :
None
O t h e r a c t i v e p ro b l e m s :
Bilateral fibrocystic breast changes
M e d i c a l , s u rg i c a l , o b s t e t r i c , h o s p i t a l i z a t i o n s :
Medical: None
Surgical: G2P2; Bilateral tubal ligation following last delivery at age 35
OB/Gyn: NSVD x two; breast fed both for 4 months; premenopausal; menses regular since age 10.5
P re v e n t i v e H e a l t h :
Pap smears in the past are negative
Diet: Tries to eat a well-balanced diet
Exercise: Walks to and from the train 5 days a week; weekend gardening
I m m u n i z a t i o n s :
Up-to-date
Vitamin E
Ibuprophen occasionally for headaches
Fa m i l y H x
Father: Hypertension, hyperlipidemia
Mother: Hx of type 2 diabetes
Sisters: No sisters
Brothers: Healthy and very physically active
S o c i a l H x
Ethnicity: Hispanic-American
Occupation: Middle-school learning specialist
Marital status: Married x ~13 years
Children: 2 sons (5ish and 7ish)
Tobacco: Never
Recreational drugs: Never
Alcohol: Wine (one glass at dinner most days)
R O S ( r e v i e w o f s y s t e m s )
G e n e r a l / C o n s t i t u t i o n a l :
Normal energy level
No sleep concerns
Weight stable
S k i n / B re a s t :
Negative except for lumpy breasts
H E E N T & N e c k :
Negative
C a rd i o v a s c u l a r:
Negative
Re s p i r a t o r y:
Negative
A b d o m e n / G a s t ro i n t e s t i n a l :
Negative
G e n i t o u r i n a r y:
Negative
M u s c u l o s ke l e t a l :
Negative
N e u ro l o g i c a l :
Negative
A l l e r g i c / I m m u n o l o g i c :
Negative
Ly m p h a t i c / E n d o c r i n e :
Negative
H e m a t o l o g i c :
Negative
P s y c h o l o g i c a l :
Negative
V i t a l s
Temp : 98.6 F
Puls e: 72, rhythm: regular
BP : left: 130/72
Res pira ti on
: 14, effort: unlabored
P h y s i c a l E x a m
We i g h t :
148.0 pounds
S k i n / B re a s t :
No pallor, jaundice, ecchymoses, or rash
Normal, symmetrical breast contour
No visible skin or nipple abnormalities
No spontaneous or expressed nipple discharge or blood
Irregular "lumpy bumpy" consistency through both breasts; no suspicious, discrete palpable lesions
Slight tenderness to exam reported
G e n e r a l / C o n s t i t u t i o n a l :
Normal energy level
No sleep concerns
Weight stable
S k i n / B re a s t :
Negative except for lumpy breasts
H E E N T & N e c k :
Negative
C a rd i o v a s c u l a r:
Negative
Re s p i r a t o r y:
Negative
A b d o m e n / G a s t ro i n t e s t i n a l :
Negative
G e n i t o u r i n a r y:
Negative
M u s c u l o s ke l e t a l :
Negative
N e u ro l o g i c a l :
Negative
A l l e r g i c / I m m u n o l o g i c :
Negative
Ly m p h a t i c / E n d o c r i n e :
Negative
H e m a t o l o g i c :
Negative
P s y c h o l o g i c a l :
Negative
V i t a l s
Temp : 98.6 F
Puls e: 72, rhythm: regular
BP : left: 130/72
Res pira ti on
: 14, effort: unlabored
P h y s i c a l E x a m
We i g h t :
148.0 pounds
S k i n / B re a s t :
No pallor, jaundice, ecchymoses, or rash
Normal, symmetrical breast contour
No visible skin or nipple abnormalities
No spontaneous or expressed nipple discharge or blood
Irregular "lumpy bumpy" consistency through both breasts; no suspicious, discrete palpable lesions
Slight tenderness to exam reported
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