Comprehensive Patient Assessment
Patient’s Current Health Status
KM is a 21-year-old, married Caucasian female who has been with her significant other since the beginning of their 10th grade year of high school. She has a history of PCOS and hyperthyroidism and has not had consistent periods every month. She has presented to the office today for a requested annual exam, to discuss results of recent CBC, CMP and TSH that was obtained at her primary care physician’s office and to review her options for her amenorrhea.
Her last menstrual cycle was 5 months ago on February 1, 2019. Her cycles have never been normal, and reports that she does not have a period every month. She is sexually active with one male partner for the past 5 years. She current does not use any method of birth control and/or protection against any STI’s. She denies any problems and does not have any complaints regarding her sexual activity. NURS 6025 Week 9 Essay Assignment
Patient History
This young ladies’ health history includes depression, hypothyroidism and PCOS. She currently takes 75mg of Effexor daily which controls her depression and 75mcg of Levothyroxine daily for her hypothyroidism, which adequately maintains her TSH at appropriate levels. She is allergic to latex, metformin and sulfur which all cause a diffuse rash all over her body. She does not have any food or environmental allergies. She denies any previous surgeries.
KM has reported that she has previously had the HPV vaccine by the age of 15 and received the influenza vaccine last season. She has never had a PAP for which she will receive in the office today and has never had a mammogram. Per the guidelines of ACOG, she will not have to complete a mammogram until the age of 40.
KM’s family history consists of breast cancer (mother/grandmother), DM (maternal grandmother), thyroid disorder (maternal grandmother) and HTN (maternal grandmother). No other members of her family have any significant health history that she aware of. Family support is available through her grandmother, parents and spouse. Her husband works long hours as an electrician but is home at nights.
Gynecological and Obstetric History
Per patient report, she has never been pregnant but has been trying for a few years; G0 P000. She was told by a previous physician that due to her PCOS it may be very difficult for her to become pregnant and that her periods may be “all over the place.” She has not used any form of contraception for this reason and has never used any barriers to STI’s. She reported that she has only been with one personal sexually. She began her period at age 11 and it was normal for the first few years. She does not report a heavy flow and when she has a period it can last anywhere from 3-7 days. Cramping is minimal and she does not have to take any medication during that time.
Social History
Patient is a 21-year-old female who graduated high school a few years ago but never had plans of attending college. She has never used alcohol or illicit drugs. She did try smoking cigarettes at one time but did not “pick up the habit.” She commutes to and from work by driving a motor vehicle. She reports the utilization of a safety belt while driving and does not use her mobile device while driving that vehicle. She walks occasionally when it’s nice outside but does not do any strenuous activity. She sleeps approximately 6-8 hours per night; denies any issues staying asleep although does have some problems falling asleep. NURS 6025 Week 9 Essay Assignment
Review of Systems
General: No unexplained weight loss or gain, no decreased appetite, no chills, no fever or fatigue.
HEENT: No blurred or loss of vision, no loss of hearing, hearing difficulty or ringing in ears, no
congestion, rhinorrhea, sore throat or hoarseness.
Integumentary: No changes in skin such as rashes, dryness or persistent itching, breasts are symmetrical and firm with no lumps.
Respiratory: No SOB, wheezing, rhonchi or rales, no cough or sputum production
Cardiovascular: No chest pain, palpitations or extremity edema; no pain with walking
Gastrointestinal: No change in bowel habits, indigestion, nausea/vomiting or diarrhea. No
abdominal pain or tenderness, no decrease in appetite.
Genitourinary: No burning with urination, no itching, reports labial/vaginal pain. Last menstrual cycle – 2/1/2019, last Pap – none, Last breast exam – none
Neurological: No dizziness, LOC or headaches. Moves all extremities without tremors
Psychiatric: No mental illness, depression or anxiety
Musculoskeletal: No muscle or joint pain
Hematologic: No anemia, bleeding, not easily bruised, no history of blood transfusions
Lymphatics: No cervical lymphadenopathy, no history of splenectomy
Endocrinological: No heat or cold intolerances, no sweating, no polyuria or polydipsia
Allergies: No history of asthma, hives, eczema or rhinitis