I. Identification Data:
Today is Sunday, April 28th 2013. My name is Herendira Valdez, I am a DNP student at ASU, and I will be performing a full physical examination on I.V., a 18 year old female. She was born in Lake Havasu, Arizona on March 1st, 1995. Patient is supplying all assessment data at this visit. She identifies herself as a Hispanic female, with Christian beliefs. She is a freshman at ASU, pursuing a biochemical engineering degree, and works 16 hrs a week caring for an autistic child. Patient relays that she plays tennis, and is highly active in church activities.
II. History of Present Illness: Patient is here today for a routine physical. She has no symptoms of illness, and has no other physical complaints.
III. Past Medical History: Patient relays that she has no significant medical history. She reports two hospitalizations in the past, the first in 2004 for a tonsillectomy, and the second in 2011 after a MVA. Patient underwent four months of physical therapy after the MVA, due to severe back pain. Since then, patient relays that she still has lower back pain on occasion, usually after strenuous activity. Pain is usually relieved with hot packs and motrin.
Patient reports having chicken pox as a child, but does not remember the year. She denies any behavioral problems, interventions or hospitalizations for psychiatric issues. Patient states that after the MVA in 2011, she felt depressed due to the physical pain she was in, but her PCP opted not to put her on medication at the time. Once her pain was under control, and physical therapy began to work for her, she felt in better spirits, and has not had issues since then.
Patient lives with birth parents, and reports that mother’s health in pregnancy was good with no complications or exposures to drugs, alcohol, or radiation. Patient denies any growth or development lags. Menses at age 14, with periods occurring 28-30 days apart. Period flow is light in consistency and patient only experiences mild cramps during…