Caroline casey ihuman

Date of encounter: 7/3/2020

Patient Name or initials: CC

Informant: Patient

Chief Complaint (CC): Patient is here to discuss contraception options and “getting

back to normal self” due to recent fatigue.

History of present illness (HPI):

Patient is a 25 y.o. African American female G1P1001 with history of a DVT who

presents to office to discuss contraception and “getting back to normal self”. Patient

recently gave birth to a son 9 months ago and felt “good” first two months after delivery

then began to develop fatigue. The fatigue has been increasing and does not improve

with sleep. Patient is also experiencing heavier periods with dime sized clots, soaking

through 4-5 tampons a day and requiring a backup pad. Patient describes her tiredness as

moderate and getting worse.

Allergies: Latex (rash)

Food allergies: Strawberries, Kiwis (trouble breathing)

Medications: Tylenol PRN

Past History: DVT

Family History: Unknown, patient was an orphan and denies knowledge about family

history

Personal and Social History:

Denies alcohol and recreational drug use.

Pertinent Review of systems (ROS):

List pertinent +. If positive, expand upon with the 7 attributes in the HPI.

General: The patient describes an overall good state of health but complains of fatigue.

Denies fever, chills, weight loss or weight gain.

Skin: Warm and dry, denies any rash skin changes, or lesions.

HEENT: Denies headache, changes in vision or throat soreness

Neck: pain, limitation of motion, lumps or swelling, enlarged or tender nodes

Breast: pain, lump, nipple discharge, rash

Respiratory: Denies shortness of breath at rest, denies cough. Complains of some

dyspnea on exertion

CV: Denies chest pain, palpitations.

GI: Normal bowel movements. Denies nausea/vomiting.

GU: Denies issues with urination, hematuria

Peripheral Vascular: Denies swelling or leg pain.

Endocrine: Denies weight loss or gain, cold intolerance, or skin changes

Neuro: LOC, seizure activity, developmental delays, nervousness, dizziness, headache,

changes in memory, changes in mood

MS: Denies weakness, denies musculoskeletal issues

Sexual Health: Uses a male condom with partner

Approved NP Faculty 3/2016