Comprehensive Clinical Assessment: Head-to-Toe
Evaluation of Laura Wood, Age 41
,
, History of Present Illness (HPI)
Laura Wood is a 41-year-old woman presenting for a
routine well-woman evaluation. She has no acute
complaints. She reports regular menstrual cycles
every 28–30 days, lasting 4–5 days, with no abnormal
bleeding, pelvic pain, or vaginal discharge. She denies
hot flashes, night sweats, or other menopausal
symptoms. She notes occasional fatigue, which she
attributes to work and family responsibilities, and
mild joint stiffness in the mornings that improves with
activity. She denies fevers, chills, unintentional weight
changes, or night sweats.
She exercises 4–5 times per week (walking and yoga),
maintains a balanced diet, and consumes alcohol
socially (1–2 drinks on weekends). She denies tobacco
or illicit drug use.
Past Medical / Surgical / Family / Social History
• Past Medical History: No chronic illnesses
reported. Denies hypertension, diabetes, thyroid
disease.
• Past Surgical History: None.
• Gynecologic/Obstetric: G2P2, vaginal deliveries.
Last Pap smear 3 years ago, normal. No history of
Evaluation of Laura Wood, Age 41
,
, History of Present Illness (HPI)
Laura Wood is a 41-year-old woman presenting for a
routine well-woman evaluation. She has no acute
complaints. She reports regular menstrual cycles
every 28–30 days, lasting 4–5 days, with no abnormal
bleeding, pelvic pain, or vaginal discharge. She denies
hot flashes, night sweats, or other menopausal
symptoms. She notes occasional fatigue, which she
attributes to work and family responsibilities, and
mild joint stiffness in the mornings that improves with
activity. She denies fevers, chills, unintentional weight
changes, or night sweats.
She exercises 4–5 times per week (walking and yoga),
maintains a balanced diet, and consumes alcohol
socially (1–2 drinks on weekends). She denies tobacco
or illicit drug use.
Past Medical / Surgical / Family / Social History
• Past Medical History: No chronic illnesses
reported. Denies hypertension, diabetes, thyroid
disease.
• Past Surgical History: None.
• Gynecologic/Obstetric: G2P2, vaginal deliveries.
Last Pap smear 3 years ago, normal. No history of
