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Sarah Fulkerson Job 26 Report 6
Sarah Fulkerson Job 26 Report 6
ADMITTING DIAGNOSES
1. Cystocele.
2. Prolapsed uterus.
3. Benign cyst of vulva.
CHIEF COMPLAINT
1. Painful menstrual flow.
2. Urinary incontinence.
PRESENT ILLNESS
This 38-year-old Native American female presented with increased
menstrual flow and stress urinary incontinence over the last two years. No
other complaints.
MEDICATIONS
None. No allergies save for a reaction to ASA.
FAMILY HISTORY
Mother has COPD. Father has hearing loss and elevated cholesterol. One
sibling with hearing loss. Maternal aunt with type 2 Diabetes Mellitus.
SOCIAL HISTORY
Divorced. Former smoker (see PMH). Drinks wine socially. Two daughters,
ages 6 and 15, in good health.
(Continued)
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Cristina Youngblood
Patient ID: 712102
Date of Admission: 06/24/2021
Page 2
PHYSICAL EXAMINATION
In general, a well-developed, well-nourished, obese American Indian woman
with stable vitals. HEENT: Normocephalic, atraumatic. No neck masses.
CHEST: Clear to P&A. HEART: Not enlarged, regular rate and rhythm. No
murmurs. BREAST: No masses. ABDOMEN: Soft, nontender. No
organomegaly. PELVIC: six centimeter superficial cyst, right upper labium
minus. Cystocele. Uterus normal size with mild prolapse. Cervix oval, clean.
Adnexa, cul-de-sac clean. RECTAL: Confirmatory. EXTREMITIES: Pulses 2+,
no edema. NEUROLOGIC EXAM: Cranial nerve II through XII intact as
tested.
DISPOSITION
Admit for possible urinary bladder repair and hysterectomy.
Kathleen J. Lorencz, MD
OB-GYN Department
KL:Sf
D: 06/24/2021
T 06/25/2021