RNR 601 wk 3 i Human notes Regina Ricardo
Regina Ricardo 65 yo, 5’5 126 lbs
C/O: Trouble sleeping, feels tired during the day. Losing weight. Feels jittery or nervous.
Location: out pt clinic with xray, ECG, and lab capabilities
Visual: Anxious looking, attentive. Alert, well-dressed, seated on table.
Skin: Palms moist
VS: Temp 99.2, Pulse 102, BP 130/72, RR: 14, SPO2: 98%, A&O x 4
PREVENTIVE HEALTH:
Colonoscopy at age 58: no polyps
Mammogram at age 64: with dense breast tissue, no obvious lesion
Optometry: last had a refraction exam 6 months ago
Pelvic / Pap exam at age 62: no lesions, masses, tenderness, pap negative
Dexa at age 62: T score of – 0.8
IMMUNIZATIONS:
Diphtheria, Tetanus, Pertussis (DTaP): received at age 61
Herpes Zoster: received at age 64
Influenza and COVID vaccine: received full dosing and most recent booster
FAMILY HX:
Father: died at 89 from pneumonia. History of asthma diagnosed 26 and osteoarthritis diagnosed
62
Mother: died age 71 in a car accident. History of hypertension diagnosed at 57
Maternal grandmother: died at 81 of a stroke. History of “lazy” thyroid
Maternal grandfather: died age 35 in war – no medical problems
Paternal grandmother: died age 76 of breast cancer
Paternal grandfather: died age 75 of prostate cancer
Two sons (ages 31 and 33): both healthy, without medical problems
No siblings
SOCIAL HX:
Tobacco: non-smoker (smoked occasionally in college)
pg. 1
, Alcohol: drinks socially (1-2 x per month, goes out with girlfriends), CAGE 0/4
Drugs: denies
Diet: general American diet with heavy protein
Activity: plays tennis on weekends and walk daily
Travel: denies recent travel
Living situation / housing: owns 2 story home with spouse
Support system: spouse, community center, and tennis friends
Occupation: retired high school science teacher
Finances: denies financial stress
Sexual history: married, monogamous, no history of STIs
Weight: lost 9 lbs
GI:
Bowel movements: a little less constipated, more frequent.
Denies nausea / vomiting
GU:
Denies change in urinary system
MUSCULOSKELETAL:
Denies bone and joint pain.
Denies muscle pain or cramping.
Denies swelling
Denies difficulty with ambulation
HEMATOLOGIC:
Denies bruising or bleeding easily, nose bleeds, and bleeding gums
ENDOCRINE:
Denies excess facial hair, change in thirst, change in urination, hot flashes, color in feet or toes,
and difficulty waking up. Sweaty hands
NEUROLOGICAL:
Denies tingling and / or numbness anywhere, headaches, seizures, lack of coordination,
dizziness, involuntary strange dance like movements, loss of consciousness, trouble with speech,
extremity weakness, memory problems Trembles in hands, illegible handwriting
PSYBHOLOGICAL:
pg. 2
Regina Ricardo 65 yo, 5’5 126 lbs
C/O: Trouble sleeping, feels tired during the day. Losing weight. Feels jittery or nervous.
Location: out pt clinic with xray, ECG, and lab capabilities
Visual: Anxious looking, attentive. Alert, well-dressed, seated on table.
Skin: Palms moist
VS: Temp 99.2, Pulse 102, BP 130/72, RR: 14, SPO2: 98%, A&O x 4
PREVENTIVE HEALTH:
Colonoscopy at age 58: no polyps
Mammogram at age 64: with dense breast tissue, no obvious lesion
Optometry: last had a refraction exam 6 months ago
Pelvic / Pap exam at age 62: no lesions, masses, tenderness, pap negative
Dexa at age 62: T score of – 0.8
IMMUNIZATIONS:
Diphtheria, Tetanus, Pertussis (DTaP): received at age 61
Herpes Zoster: received at age 64
Influenza and COVID vaccine: received full dosing and most recent booster
FAMILY HX:
Father: died at 89 from pneumonia. History of asthma diagnosed 26 and osteoarthritis diagnosed
62
Mother: died age 71 in a car accident. History of hypertension diagnosed at 57
Maternal grandmother: died at 81 of a stroke. History of “lazy” thyroid
Maternal grandfather: died age 35 in war – no medical problems
Paternal grandmother: died age 76 of breast cancer
Paternal grandfather: died age 75 of prostate cancer
Two sons (ages 31 and 33): both healthy, without medical problems
No siblings
SOCIAL HX:
Tobacco: non-smoker (smoked occasionally in college)
pg. 1
, Alcohol: drinks socially (1-2 x per month, goes out with girlfriends), CAGE 0/4
Drugs: denies
Diet: general American diet with heavy protein
Activity: plays tennis on weekends and walk daily
Travel: denies recent travel
Living situation / housing: owns 2 story home with spouse
Support system: spouse, community center, and tennis friends
Occupation: retired high school science teacher
Finances: denies financial stress
Sexual history: married, monogamous, no history of STIs
Weight: lost 9 lbs
GI:
Bowel movements: a little less constipated, more frequent.
Denies nausea / vomiting
GU:
Denies change in urinary system
MUSCULOSKELETAL:
Denies bone and joint pain.
Denies muscle pain or cramping.
Denies swelling
Denies difficulty with ambulation
HEMATOLOGIC:
Denies bruising or bleeding easily, nose bleeds, and bleeding gums
ENDOCRINE:
Denies excess facial hair, change in thirst, change in urination, hot flashes, color in feet or toes,
and difficulty waking up. Sweaty hands
NEUROLOGICAL:
Denies tingling and / or numbness anywhere, headaches, seizures, lack of coordination,
dizziness, involuntary strange dance like movements, loss of consciousness, trouble with speech,
extremity weakness, memory problems Trembles in hands, illegible handwriting
PSYBHOLOGICAL:
pg. 2
