The Patient Is A 38 Year Old Caucasian Female

974 Words Dec 19th, 2016 4 Pages
The patient is a 38-year-old Caucasian female. Patient’s date of birth is May 22,

1978. She is Catholic and attends church every Sunday. She currently works at Chino

Valley Medical Center as a medical assistant. The patient has asthma but indicates she

only uses her inhaler while exercising. There is no history of surgeries. She has a history

of hypothyroidism and high cholesterol levels. As a child, she had pneumonia and was

hospitalized for 2-3 days. Her last physical examination was March 2016. In November

2016, the patient states that she had inflammation in her left forearm, which was causing

extreme pain only at night, due to the pain affecting the patient’s daily activities she was

prescribed methylpredisone 4mg for 6 days and ibuprofen 600 mg PRN for pain. Her last

menstrual period was December 2, 2016.

Patient is currently only taking levothyroxine 200 mcg and vitamins. Patient

states that she has seasonal allergies, but takes medication to prevent symptoms by taking

Benadryl 10mg per day as needed. Patient states she does not have any allergies to any

medications. Patient has no history of tobacco use or recreational drug use. She rarely

drinks alcohol, only at social events. Patient states she drinks wine twice a week. Patient

has caffeine in the form of coffee almost everyday. Immunization records of the patient

show that she is immune to Hepatitis B and C, tetanus, measles, mumps, and rubella

(MMR), chicken pox and the current…
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