Comprehensive Health Assessment
LETTICA JOHNSON
September 17, 2013

9/17/2013 15:30 PM

S:Mrs. Easter is a pleasant, but very anxious, 32 year old married mother of 2 residing in Houston, TX and is an Executive Administrative Assistant and business owner.
Referral: None
Reliability: Self-referred; seems reliable.
Chief Complaint:Patient complained of “shaky hands”
Present Illness: For the past year Mrs. Easter has had a problem with unsteady hands and palpitations in her heart. She was seen in the emergency room one month ago due to what she felt was a possible heart attack at the time. The emergency room physician diagnosed a panic attack and possible Generalized Anxiety Disorder. She has also had recent episodes of blurred vision along with sharp headaches in the back of her head. The pain is usually moderate and lasts about 20-30 seconds. The patient reports being diagnosed with pre-hypertension at the age of 25 and was prescribed Metoprolol, which the patients has refused to take. The blood pressure recorded at that time was 142/89.
Medications:Patient is prescribed Metoprolol 50mg, denies taking as perscribed
Allergies: Patient reports Doxycycline and Celcor severe allergy causes rash, swelling, vomiting, and bleeding Tobacco:Denies tobacco usage.
Alcohol:Patient reports wine on rare occasions.
Past History:

Childhood Illnesses. Patient reports history of Bilateral Glue Ear, Chicken Pox, and Asthma. Denies history Scarlet Fever or Rheumatic Fever.
Adult Illnesses. Medical: Pre-hypertension, 2006 treatment refused by patient. Surgical: Grommet insertion, 1983; Laparoscopic Ovarian Cystectomy, 2007; Cholecystectomy, 2010; Appendectomy, 2011; Laproscopic Salpingostomy, 2013. Ob/gyn: 1 normal vaginal delivery, 1 ecotopic pregnancy; last menses 1 month ago. Psychiatric: GAD, 2013 treated with alprazolam .5mg.
Social History:Born in Fort Hood, TX at Darnell Hospital. Patient comes from a military back ground. Mother has had 3 marriages that have failed. Patient was married at 29 years old. It is the only marriage patient has had. Patient was involved in a car accident in 2009 and struck the front of head and back of head on dashboard and windshield, patient reports hospital found no injuries. Patient has only a few select “friends” and rarely attends any social events. Patient works as an Executive Administrative Assistant to the owner of a construction business in Houston, and also owns and operates an energy business. Patient has very little free time and the time she has is filled with church obligations. She feels stressed that “there is never enough time.” * Exercise and diet. Patient reports moderate exercise. Patient reports diet high in carbohydrates and low in fat.

Review of Systems:
*General. Patient reports she has gained 5 lbs. in past 4 years.
Skin. Patient denies rashes or other changes in the skin.
Head, Eyes, Ears, Nose, Throat (HEENT). See Present illness. Patient denies history of head injury. Patient denies any blunt hits to the head. Patient denies any bouts of unconsci Eyes: Reading glasses for 6 years. Last checked 2 years ago. Eye infection due to allergies 1 year ago, treated with Vigamox. No reoccurrence.Ears:see Childhood Illnesses. Patient denies any current issues. Nose, sinuses: Season allergies, exact allergens are unknown. Sinus clear. Throat: Patient denies any symptoms.
Neck: Patient denies lymphs, goiter, and pain. Patient reports no swollen glands.
Breasts: Patient reports no lumps, apins, or discharge. Patient reports she does self-exam monthly.
Respiratory: Patient deniesany cough, wheezing, or shortness of breath. Patient denies having received any chest x-ray.
Cardiovascular: Patient reportspre-hypertension diagnosed 2006. Patients denies any known heart disease, dyspnea, orthopnea, and patient reports last electrocardiogram 2013.
Gastrointestinal: Patient reportsappetite has slowed since gallbladder removed. Patient reports nausea some mornings, due to bile accumulation in stomach. Patient reports bowel movement 2 times a day. Patient denies any diarrhea or bleeding. Patient reports no jaundice.
Urinary: Patient reportsno symptoms. Patient denies any bladder infections. Patient denies UTI. Patient denies any kidney problems. Patient reports normal urination.
Genital: Patient denies anyvaginal or pelvic infections.
Peripheral Vascular: Patient denies any symptoms.
Musculoskeletal: Patient reportsmild, aching lower back pain after standing or walking any extended length of time; no radiation down the legs. Patient reports mild knee pain when knees are bent for an extended period of time.
Neurologic: Patient reportsno fainting, seizures, motor or memory loss.
Hematologic: Patient reports no symptoms
Endocrine: Patient reportsno known thyroid trouble.
Psychiatric:Patient denies any depression. See Present Illness.