FOR SOLUTION PRO: Paper

Identifying Data

Patient Initials E.R.

City/State Los Angeles, California

DOB April 14, 1985

Age 30

Gender Female

Race/Ethnicity Hispanic

Marital Status Single

Children 2 males age 5 and 10

Occupation Stay home mother

Chief Complaint

“I am experiencing migraines for the last week”.

History Of Present Illness

Sharp and throbbing pain at the frontal and occipital of head for the past 7 days. Pain comes and goes with pain scale of 7 out of 10. Pain worsens by stress and thoughts of her grandparents passing. Pain is relieved when she takes Ibuprofen 800mg and naps.

Past Medical History

Childhood Illnesses Chicken pox at 5 years of age without complications. Denies measles, german measles, mump, whooping cough, rheumatic fever or scarlet fever, and polio.

Immunizations Flu vaccine 2015, tetanus 2014, pertussis 2014, diphtheria 2014. Doesn’t remember the dates for measles, german measles, mumps, hepatitis a&b, and pneumococcal.

Adult Illnesses Migraines for the past 8 years and currently being seen by Rosales, PA at Family Care Specialist Medical Group. Asthma for the past 21 years and currently being seen by Rosales, PA at Family Care Specialist Medical Group. Never been hospitalized for these illnesses.

Psychiatric Illnesses Denies any psychiatric illness.

Surgical History Denies history of surgeries.

Trauma, Injuries or Accidents MVA in 2013 (rear ended) in Los Angeles and was rx NSAID for neck/body pain.

Obstetric History (female only) G:3 (history of 1 induced abortion), P:2 (both are males NSVD without complications during pregnancy).

Transfusion History Denies history of transfusions.

Current Health Status

Medications Amitriptyline HCL 25mg PO QD at night. (Started: April 2014, Classification: Analgesics, Mechanism of action: Inhibits norepinephrine and serotonin reuptake, Adverse reactions: Hypotension- orthostatic, htn, syncope, Side effects: Drowsiness, dizziness, constipation, Special related tests: serum drug levels, ecg, and in peds bp and hr. Taking medication as directed without any assistance (Epocrates, 2015).

ProAir HFA 90 mcg PO 2 puffs q4h (inhalant) PRN. (Started: at the age of 21 years old, Classification: Beta-2 agonists 1: short acting inhalant, Mechanism of action: Selectively stimulates beta-2 adrenergic receptors, relaxing airways smooth muscle, Adverse reactions: Bronchospasm- paradoxical, anaphylaxis, hypersensitivity, arrhythmia, Side effects: Cough, bad taste, nausea, headache, throat irritation. Taking medication as directed without any assistance (Epocrates, 2015).

Ibuprofen 800mg PO q8h PRN. (Started: 2010, Classification: Analgesics/NSAID, Mechanism of action: Inhibits cyclooxygenase, reducing prostaglandin and thromboxane synthesis, Adverse reactions: GI bleeding, GI perforation/ulcer, MI, strokes, Side effects: nausea, dizziness, constipation, tinnitus, Special related tests: CBC, chemistry profile if long-term tx; BP; s/sx hepatic impairment in peds. Taking medication as directed without any assistance (Epocrates, 2015).

Allergies (drug reactions) Imitrex (sob) 2 years ago. Denies allergies of food.

Health Screenings States “normal” for Pap 2012, cholesterol 2015, chest x-ray 2014, tb test 2013, SBE (monthly) April 2015. Denies having an ekg, fobt, mammography, and rectal exam.

Habits Denies tobacco, alcohol, drug use.

Alternative Therapies Denies history of alternative therapies.

Psychosocial History

Marital Status/significant others Not married. Has male partner of 7 years.

Living conditions Lives with mother, father, 2 children, brother, and nephew.

Domestic Violence (IPV or Abuse) Denies ipv or abuse.

Employment/economic concerns Unemployed. No economic concerns.

Education Medical assistant certificate 2007, high school diploma 2004.

Sexual History Sexually active with male (fidelity). Denies history of std’s, sexual difficulties, and sexual habits.

Significant life events Grandparents death in 2014 and 2015. Denies financial hardship, alcoholism, relocation, and abuse.

Mental status Anxiety and depression since 2014. Denies mood changes, stress, and memory changes.

Spiritual Assessment

Faith Affiliation Catholicism

Spiritual or faith practices Attends church.

Places of hope Church and home.

Things, practices or people that provide support and peace Family members and priests from church.

Family History

See attached genogram

Family Illnesses (positives and negatives)

Review of systems

General Considers to be a healthy individual. Usual weight of 150 lbs, appetite is 3 meals and 2 snacks per day, recent weight loss of 5 lbs during the past month. Denies weakness, fatigue, and fever.

Skin Denies rashes, lumps, itching dryness, color changes, and changes in hair or nails.

Eyes Last eye exam (optometry) 2015 and was told has stigmatism and rx glasses (doesn’t know rx). Denies pain, redness, excessive tearing, double vision, and transient loss or impairment of vision.

Ears Last hearing exam (audiometer) 2014 and results were “okay”. Denies use of hearing device, hearing changes, sensation of spinning, earaches, infection, discharge, and ringing.

Nose/sinuses Denies frequent colds, nasal stuffiness, hay fever, and nose bleeds.

Mouth/throat Last dental exam 2012 and results were 2 root canals and 1 crown. Condition of teeth and gums “good”. Denies bleeding gums, sore tongue, frequent sore throats, hoarseness, bad breath, change in voice, and loss of or peculiar taste.

Head/neck History of migraines and headaches. Denies double visions lumps in neck, swollen glands, and pain or stiffness in neck.

Breasts Pap 2012 and results “normal”. SBE done monthly and last was April 2015. Denies lumps, pain, and nipple discharge.

Respiratory History of Asthma since 21 years old with several wheezing episodes, Last TB test 2014 (negative), chest x-ray 2014 (“normal”). Denies cough, sputum, coughing blood, bronchitis, emphysema, pneumonia, and pleurisy.

Cardiac History of sob with exertion related to asthma. Denies chest pain, rapid or skipped heartbeats, swelling, history of MI, or abnormal cholesterol levels.

Gastrointestinal Denies trouble swallowing, heartburn, nausea, vomiting of blood, indigestion, changes in bowel habits, rectal bleeding or black tarry stools, constipation, diarrhea, abdominal pain, food intolerance, excessive belching, or passing of gas, hemorrhoids, liver or gall bladder trouble, hepatitis, and jaundice.

Urinary Denies increased frequency of urination, increased volume of urine, urination during usual sleeping hours, immediate need to urinate, problem in initiating urination, involuntary loss of urine, blood in urine, and history of urinary stones.

Genitor-reproductive Age of onset menses at 12 years old. Monthly menstruations with 4-5 days of duration (last May 6, 2015). Denies bleeding between periods or after intercourse, last menstrual period, excessive pain during menstrual flow, age at cessation of menstrual period, menopausal symptoms, post​menopausal bleeding, and vaginal discharge or itching. Birth control methods (condoms).

Musculoskeletal Denies joint pains or stiffness, arthritis, gout, backache, and muscle pains or cramps.

Neurological History of depression related to grandparents death in 2014 and 2015. Denies nervousness, tension, mood.

Endocrine Denies thyroid trouble, heat or cold intolerance, excessive sweating, diabetes, excessive thirst, eating or urination.

Hematologic Denies anemia, easy bruising or bleeding.

Pertinent Health Problems List

Migraines

Asthma

Depression

Anxiety

Medical Diagnoses

Migraines, chronic (ICD-10: G43)

Asthma, mild intermittent (ICD-10: J45.20)

Depression, severe (ICD-10: F33.3)

Anxiety, unspecified (ICD-10: F41.8)