Name: Ms.

Sara Kuhl DOB: September 4, 1982 Date: April 21, 2015

SUBJECTIVE:
CC: Mrs. Kuhl comes in today for wellness visit
PMH/PSH: No prior illnesses and injuries, no operations and hospitalizations,
immunizations UTD.
ALLERGIES: NKDA, no latex or food allergies.
MEDICATIONS: None
FH: Biological parents and grandparents alive and well.
SH: Married, monogamous, STD negative, feels safe at home. Works FT as an RN. No
tobacco use, no use of illicit drugs, and no use of alcohol.
HEALTH PROMOTION
Annual checkup: Womens health exam/pap smear last year.
Self-breast exam: Regularly
Vision: Ophthalmic exam in the last month.
Dentist: Visit in the last year.
Exercise: Moderate exercise 3x/week.
Safety: Uses seat belts every time rides in a car.
Sleep: 6-7 hours a night, no hx insomnia.
Personal Hygiene: Usually does not use feminine sprays, ointments, creams, or douches.
NUTRITION:
Diet 24-hour recall
Breakfast: Bagel and cream cheese.
Lunch: Sandwich and fruit.
Snack: Chips or pretzels in later afternoon.

Dinner: Chicken and rice.

Late snack: Sometimes cake or ice cream.
Water: Drinks 8-10 glasses of water a day.
ROS :
GENERAL: Denies fever, chills, or malaise. Denies any pain. Present symptoms do not
limit her activities. Pt with good energy level.
HEENT:
Head: Denies H/A, head trauma, or hair loss.
Eyes: Denies blurry vision, double vision, or eye discharge.
Ears: Denies hearing loss, ear discharge or ear pain.
Nose: Denies nosebleeds, rhinorrhea, or loss of smell.
Throat: Denies sore throat, exudates, or trouble swallowing.
PULMONARY: Denies SOB, cough, or wheezing.
CARDIOVASCULAR: Denis chest pain, palpitations, or leg swelling.
SKIN: Denies rashes, itching or growths.
GASTROINTESTINAL: Denies abdominal pain, nausea, vomiting, and diarrhea.
GENITOURINARY: Denies burning on urination, excessive frequent urination or
urgency. LMP 3/12/15. Normal menstrual periods monthly. Menarca at 13 years old.
NEUROMUSCULAR: Denies joint pain, stiffness, or limitation in movement.
HEMATOLOGIC: Denies unexplained bruising or bleeding.
ENDOCRINE: Denies, polyuria, polydipsia, or polyphagia.
METABOLIC: Denies excessive discomfort when exposed to cold or heat, dizziness
upon standing or sitting up, or shakiness if skips meals.
PSYCHIATRIC: Denies feelings of depression or sadness, denies any suicidal thought.
OBJECTIVE DATA:

PHYSICAL EXAMINATION:
GENERAL: Mrs. Kuhl is a 32 year-old female oriented to person, place, and time. Mood
and affect normal and appropriate to situation, well groomed. No signs or symptoms of
acute distress.
VITALS: T 98.6 F, P 88 bpm, R 16 rpm, BP 124/60 mmHg.
Ht 56 Wt 140 BMI 24.3.
HEAD: Normocephalic without trauma and with normal hair distribution pattern and no
oiliness.
EYES: Eyes symmetric, sclera white, PERRLA
EARS: External auditory canals are patent and clear. Tympanic membranes are without
effusion, erythema, or loss of landmark or immobility.
NOSE: Nasal septum is midline, without deviation or perforation. Nares are free of
congestion, or epistaxis. Turbinates are pink and nares are moist
MOUTH/THROAT: Adequate oral hygiene is apparent, no thrush or lesions, mucous
membrane moist. No inflammation or exudative discharge in the oropharynx, and tongue
is midline. Soft palate is confluent with hard palate.
NECK: soft and supple, no carotid bruits, no lymphadenopathy, or thyroid abnormalities.
Midline trachea.
SKIN: Warm and dry to palpations, intact, no rash, and no lesions.
CARDIOVASCULAR: Regular heart rate and rhythm, no murmurs, or extra sounds.
Normal S1, S2 without splitting. No bruits. Pulses 2+.
PULMONARY: Bilateral lung sounds are clear throughout with no evidence of
wheezing, rhonchi, rales, or rubs. Normal inspiratory and expiratory phases. Not labored.
No use of accessory muscles or intercostal retraction noted. Thorax is symmetrical with
normal excursion. Normal percussion bilaterally. Egophony and tactile fremitus normal.
ABDOMEN: Abdomen is flat, soft, non-tender to palpation, bowels sounds present in all
4 quadrants, without abdominal bruits. No rebound, rigidity, or guarding. No masses or
organomegaly. No aortic bruit. Tympani on percussion, dullness over liver and spleen.
NEUROMUSCULAR: Posture erect without deformities, gait stable, joints mobile, nontender; full ROM. Muscle strength +5, equal bilaterally.
NEURO / PSYCH: CN 1-12 intact. DTRs 2+. Romberg negative.

Intact recent and remote memory. Judgment and insight normal. Good eye contact, mood
and affect normal. Denies any sleep disturbances.
DX TESTS: None needed.
ASSESSMENT:
1.

Health promotion

PLAN/TREATMENT:
- Follow-up in one year and as needed.