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Name: Vivian Lopez Pt. Encounter Number: Date: 06/05/2025 Age: 24 Sex: Female SUBJECTIVE CC: “Im doing good, Im just here to establish some basic care” HPI: OLD CARTS: (^) Onset: No current complaints (^) Location: General wellness care; no localized concerns (^) Duration: No changes in health; routine wellness visit (^) Characteristics: No symptoms reported (^) Aggravating/Relieving Factors: No factors impacting health (^) Timing: Ongoing well-being maintenance (^) Severity: No reported issues No current health complaints. No history of chronic illness. Currently taking Apri (ethinyl estradiol 0.03 mg / desogestrel 0.15 mg) once daily for contraception. No medication intolerances or allergies. Previous right arm fracture at age 10, no ongoing issues. No prior surgeries. Medications: Apri (ethinyl estradiol 0.03 mg / desogestrel 0.15 mg) once daily for contraception. Allergies: Denies any Allergies to medications Medication Intolerances: Denies medication intolerances Past Medical History: Right arm fracture at 10 years old
Chronic Illnesses/Major traumas: Denies Hospitalizations/Surgeries: Reports hospitalization for right arm fracture at 10 years old, denies any surgeries “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis? Patient denies all these questions Family History Mother, father, and two siblings (Ana and Jacob) all healthy. No family history of lung disease, heart disease, hypertension, cancer, tuberculosis, diabetes, or kidney disease. Social History Holds a bachelor’s degree in social media and marketing. Works as a marketing associate. Lives with girlfriend, identifies as bisexual. Drinks wine socially and occasionally consumes marijuana (either smoking or edible). Feels safe at home. ROS Student to ask each of these questions to the patient: “Have you had any…..” General (^) No recent weight changes. (^) No fatigue, fever, chills, or night sweats. Cardiovascular (^) No chest pain or pressure. (^) No palpitations or irregular heartbeats. (^) No orthopnea (difficulty breathing while lying down). (^) No paroxysmal nocturnal dyspnea (waking up short of breath at night). (^) No edema (swelling in lower extremities). Skin (^) No delayed wound healing. (^) No rashes or itching. (^) No easy bruising or unexplained Respiratory (^) No cough or wheezing. (^) No hemoptysis (coughing up blood).
Breast (^) No lumps, masses, or tenderness. (^) No nipple discharge or skin dimpling. Neurological (^) No dizziness or fainting (syncope). (^) No seizures or tremors. (^) No transient paralysis or weakness. (^) No numbness or tingling (paresthesias). (^) No blackout spells. Heme/Lymph/Endo (^) Unknown HIV status. (^) No unexplained bruising or prolonged bleeding. (^) No history of blood transfusions. (^) No swollen glands or night sweats. (^) No excessive thirst or hunger. (^) No heat or cold intolerance. Psychiatric (^) No symptoms of depression or anxiety. (^) No sleep disturbances or excessive fatigue. (^) No history of suicidal ideation or attempts. (^) No psychiatric diagnoses. OBJECTIVE Weight 108lbs BMI 18.0 Temp 36.5 BP 118/ Height 5’5” Pulse 89 Resp 18 Assessment General Appearance (^) Healthy-appearing 24-year-old female, well-nourished and in no acute distress. (^) Alert and oriented to person, place, time, and situation; answers questions appropriately. (^) Initially presents with a slightly somber affect, but becomes more engaged and brighter as the interaction progresses. (^) Maintains appropriate posture and eye contact throughout the examination. Skin (^) Brown, warm, dry, clean, and intact with no visible rashes, lesions, or abnormal pigmentation. (^) No evidence of delayed wound healing, bruising, or excessive dryness. (^) Nail beds pink, no clubbing or cyanosis. HEENT (Head, Eyes, Ears, Nose, Throat) (^) Head: Normocephalic, atraumatic, and symmetrical. Hair evenly distributed with normal texture. No visible or palpable masses, depressions, or scarring. (^) Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA). Extraocular movements intact (EOMI). No conjunctival or scleral
injection. No discharge or excessive tearing. (^) Ears: External ears symmetrical, no lesions or tenderness. Canals patent, bilateral tympanic membranes pearly gray with positive light reflex; landmarks easily visualized. No hearing deficits noted. (^) Nose: Nasal mucosa pink and moist, normal turbinates. No septal deviation or nasal discharge. No tenderness over sinuses. (^) Neck: Supple with full range of motion. No cervical lymphadenopathy or occipital nodes. No thyromegaly or nodules. No jugular venous distension. (^) Oral Cavity & Pharynx: Oral mucosa pink and moist. Teeth in good repair, no visible cavities or gum disease. Pharynx nonerythematous and without exudate. No hoarseness or throat pain. Cardiovascular (^) S1, S2 present with regular rate and rhythm. No murmurs, rubs, clicks, or extra heart sounds. (^) Capillary refill within two seconds. (^) Peripheral pulses 3+ bilaterally (radial, dorsalis pedis, posterior tibial). No edema or varicosities noted. (^) No jugular venous distension (JVD) or signs of circulatory compromise. Respiratory (^) Symmetric chest wall movement. (^) Respirations regular and unlabored. No use of accessory muscles. (^) Lungs clear to auscultation bilaterally. No wheezing, rales, rhonchi, or diminished breath sounds. (^) No history of asthma, pneumonia, or chronic lung disease. Gastrointestinal (^) Abdomen soft, nontender, and non-distended. (^) Bowel sounds active in all four quadrants. (^) No hepatosplenomegaly, masses, or tenderness. (^) No visible hernias or surgical scars. (^) No signs of gastrointestinal distress (nausea, vomiting, diarrhea, constipation). Breast (^) No palpable masses, tenderness, or skin changes. (^) No nipple discharge, dimpling, wrinkling, or discoloration. (^) Recommended: Monthly self-breast exams and clinical breast exam every 1-3 years per guidelines. Genitourinary (^) Bladder nondistended; no costovertebral angle (CVA) tenderness. (^) External genitalia: Coarse pubic hair in normal distribution; skin color consistent with general pigmentation. No vulvar lesions noted. (^) Speculum exam: Vaginal walls pink and well rugated; no lesions noted. Cervix pink and nulliparous. Scant clear to cloudy drainage present. (^) Bimanual exam: Cervix firm, no cervical motion tenderness (CMT). Uterus anteverted, positioned behind a slightly distended bladder; no fullness, masses,
o (^) Clinical Considerations: Screening for ferritin levels may be beneficial, especially if dietary intake is low or periods are heavy (Johnson et al., 2023). Final Diagnosis: Routine Wellness Visit Pathophysiology & Rationale (^) The patient has no acute complaints and presents for preventive care. (^) No abnormal findings requiring intervention were identified. (^) Screening labs (CBC, lipid panel, STI testing, Pap smear) are ordered per USPSTF guidelines (Moyer, 2023). References (^) Camaschella, C. (2024). Iron deficiency anemia: Pathophysiology and clinical implications. The Lancet Hematology, 11 (2), 123-135. (^) Hooton, T. M., Nicolle, L. E., & Gupta, K. (2023). Asymptomatic bacteriuria: Clinical considerations and management. New England Journal of Medicine, 389 (4), 215-225. (^) Johnson, A. B., Smith, R. T., & Lee, M. (2023). Iron deficiency in young women: Screening and prevention strategies. Journal of Women's Health, 32 (1), 45-58. (^) Moyer, V. A. (2023). USPSTF guidelines for preventive care in young adults. American Family Physician, 108 (3), 145-160. (^) Nicolle, L. E. (2024). Management of asymptomatic bacteriuria: Current perspectives. Clinical Infectious Diseases, 78 (1), 12-20. (^) Soper, D. E. (2023). Physiologic vaginal discharge: Normal variations and clinical assessment. Obstetrics & Gynecology, 141 (5), 987-995. (^) Workowski, K. A., Bachmann, L. H., & Chan, P. A. (2023). Sexually transmitted infections treatment guidelines. CDC Guidelines, 72 (4), 1-50. Plan (^) Recommended Screening Tests (^) Routine Blood Work (^) Complete Blood Count (CBC) – Screens for anemia, infection, and overall blood health. (^) Lipid Panel – Recommended every 5 years starting at age 20 to assess cardiovascular risk. (^) Blood Pressure Screening – Every 3-5 years if normal; more frequently if risk factors exist. (^) Diabetes Screening (HbA1c or fasting glucose) – If overweight or has risk factors. (^) Sexual & Reproductive Health (^) Pap Smear (Cervical Cancer Screening) – Every 3 years for ages 21-29. (^) HPV Testing – Not routinely recommended for ages 21-29, but may be done if abnormal Pap results. (^) Sexually Transmitted Infection (STI) Panel – Chlamydia, gonorrhea, HIV, syphilis (recommended for sexually active individuals).
(^) Hepatitis C Screening – One-time test for adults 18-79. (^) Additional Preventive Screenings (^) Urinalysis – Routine wellness check. (^) Vision Screening – Every 5-10 years if no risk factors. (^) Depression Screening – Recommended at routine exams. (^) Obesity Screening (BMI Calculation) – At routine exams. (^) Preventive Health Recommendations (^) Breast Exams: Monthly self-breast exams and clinical breast exam every 1-3 years. (^) Vaccinations: Ensure HPV, Tdap, flu, and COVID-19 vaccines are up to date. (^) Lifestyle Counseling: Discuss diet patient is underweight, exercise, alcohol, and substance use. (^) Medications: Continue Apri (ethinyl estradiol 0.03 mg / desogestrel 0. mg) once daily for contraception. (^) Non-pharmacological recommendations: Encourage hydration, urinary health education, and safe sexual practices. (^) Diagnostic tests: Screening labs ordered per guidelines. (^) Patient education: Apri (ethinyl estradiol/desogestrel) Education: (^) Take at the same time daily to maintain effectiveness. (^) If a dose is missed, follow package instructions for catching up. (^) May cause nausea, headaches, or breast tenderness usually resolves in a few months. (^) Increased risk of blood clots, especially in smokers or those over 35. (^) Does not protect against STIs use barrier protection if needed. (^) Report any sudden chest pain, severe headaches, or vision changes immediately. (^) Culture considerations: Respectful and inclusive care approach, tailored to patient’s social history. (^) Health promotion: Recommended annual women’s health screenings, including Pap smear and STI testing. (^) Referrals: None required at this time. (^) Follow-up: Return in 1 year for routine wellness check unless concerns arise. References Camaschella, C. (2024). Iron deficiency anemia: Pathophysiology and clinical implications. The Lancet Hematology, 11 (2), 123-135.
