Female Adult Wellness

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for a health maintenance check-up

Last check-up was ‍ ‍years ago



Current symptoms: ‍ ‍noneno changes in health



Medications:

‍ ‍none

Adherence: ‍goodaveragepoor, ‍adverse effects

Over-the-counter supplements: ‍ ‍none, ‍vitamin D, ‍calcium



Past medical history: ‍ ‍unremarkable



Family history: ‍unremarkable, ‍CAD, ‍stroke, ‍diabetes, ‍colon cancer, ‍breast cancer, ‍ovarian cancer



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU

Diet: ‍goodaveragepoor, ‍high in salt, ‍high in carbs, ‍high in fat, ‍vegan

Physical activity: ‍adequateaveragesedentary

Weight: ‍ ‍lbskg, ‍gainunchangedloss

Occupation: ‍



Labs: ‍unremarkable

Creatinine: ‍ ‍normal

Na: ‍ ‍normal, K: ‍ ‍normal

Hb: ‍ ‍normal

HbA1c: ‍ ‍normal

Lipids: ‍normal, Cholesterol: ‍, LDL: ‍, HDL: ‍, Triglycerides: ‍

TSH: ‍ ‍normal

Urinalysis: ‍ ‍normalproteins

‍



Screenings:

Dyslipidemia: ‍ ‍duenot recommended

Diabetes: ‍ ‍duenot recommended

Colon cancer: ‍ ‍duenot recommended

Breast cancer: ‍ ‍duenot recommended

Cervical cancer: ‍ ‍duenot recommended

STIs: ‍ ‍duenot recommended

Osteoporosis: ‍ ‍duenot recommended

Depression: ‍ ‍duenot recommended



Vaccinations:

Pneumococcal: ‍up-to-dateincompleteunvaccinated

Influenza: ‍up-to-dateincompleteunvaccinated

Covid: ‍up-to-dateincompleteunvaccinated

Zoster: ‍up-to-dateincompleteunvaccinated

Tdap: ‍up-to-dateincompleteunvaccinated

HPV: ‍up-to-dateincompleteunvaccinated

Hepatitis A: ‍up-to-dateincompleteunvaccinated

Hepatitis B: ‍up-to-dateincompleteunvaccinated





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Head: ‍normocephalicatraumatic, scalp ‍normalrashlesion

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal, cornea ‍intact, ‍PERRL, extraocular movements ‍intact, OD 20/‍, OS 20/‍

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Breasts: ‍normal, ‍mass, ‍axillary adenopathy

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, ‍blood, ‍mass, anus ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Good health overall





PLAN:

Investigations:

- Pap smear

- Mammogram

- Colonoscopy

- FIT test

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍LFTs, ‍albumin, ‍TSH, ‍lipid profile, ‍fasting glucose, ‍HbA1c

- Bone density test

Treatments:

- Dietary counseling: balanced diet rich in fruits, vegetables, lean proteins, and whole grains

- Exercise counseling: at least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic activity per week, plus muscle-strengthening activities twice per week

- Weight management counseling

- Smoking cessation counseling

- Alcohol moderation counseling

- Vaccinations: annual ‍influenza, ‍pneumococcal if aged ≥ 65 or conditions, ‍shingles if aged 50 and older, ‍tetanus/diphtheria every 10 years, ‍HPV

Further care:

- Follow-up in ‍ ‍monthsyears

- Return if new symptoms develop or condition worsen