Comprehensive Medical Report Essay

1145 WordsMar 17, 20125 Pages
Data: 06/03/09 Identifying Data: Name: J. Smith Sex: female Age: 44 Occupation: community college administration assistant Reliability: good CC: bilateral shoulder stiffness, right elbow pain HPI: Ms. Smith presents to the office with bilateral shoulder stiffness and lateral elbow pain in right arm. The patient has been suffering shoulder stiffness for over 2 years. The symptom developed gradually after she started using her computer more at her work place; she had to hold her telephone between her shoulder and head while typing information on computer. The pain in right elbow stated about 8 months ago with gradual onset. The patient does not recall any trauma to the shoulder and elbow. She has been diagnosed as tennis…show more content…
oots for HPB in April 2009 Cancer prevention: annual OBGYN checkup including mammogram, no abnormality detected on last checkup in February 2009 Vision screening: regular screening every 6 months, no abnormality detected on last checkup in February 2009 Dental care: regular screening every 6 months, no abnormality detected on last checkup in February 2009 ROS: General: no history of weight change, fever or chills, weakness, fatigue, or change in appetite; occasional difficulty falling asleep, mostly associated with stress from work Integument: N/A Hematopoietic: N/A Eyes: N/A Ears: N/A Nose/throat/sinuses: N/A Mouth: N/A Pulmonary: N/A Breasts: N/A Cardiovascular: N/A Gastrointestinal: occasional heartburn and bloating, especially after consumption of Indian foods; no history of nausea, vomiting, bowel changes, melena, hematochezia, dysphagia, jaundice, abdominal pain reported Urinary: N/A Geniral/Reproductive: N/A Menses: 26-27 days of cycle duration, 3 days of actual bleeding and 1-2 days of spotting afterword, moderate flow of bright red blood, no clots; mild increase in appetite 2-3 days prior to periods, no other PMS symptoms; no history of dysmenorrhea or abnormal bleeding; no menopausal symptoms Endocrine: N/A Musculoskeletal: bilateral shoulder stiffness and lateral elbow pain in right arm (see HIP) Neuro: rarely experiences headache; no history of syncope,
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