HISTORY AND PHYSICAL EXAMINATION

PATIENT NAME: Christina Youngblood

PATIENT ID: 712102

ROOM NO.: 418

DATE OF ADMISSION: 06/24/2018

ADMITTING PHYSICIAN: Kathleen J. Lorencz, MD

ADMITTING DIAGNOSIS
Cystocele.

CHIEF COMPLAINT
Urinary incontinence.

PRESENT ILLNESS
This 38-year-old Native American female presented with urinary
incontinence over the last 2 years. No other complaints.

PAST MEDICAL HISTORY

Essentially negative except for pyelonephritis as a child with no sequelae.
Scarlet fever at age 19 with subsequent tonsillectomy. Has had “sinus
trouble” in the past, which cleared after she stopped smoking. (Smoked
approximately a pack a day between the ages of 16 and 26 years.)

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.

PHYSICAL EXAMINATION
In general, a well-developed, well-nourished, obese American Indian woman
with stable vitals.
HEENT
Normocephalic, atraumatic. No neck masses.
(Continued)
Patient Name: Christina Youngblood
Patient ID: 712102
Date of Admission: 06/24/2018
Page 2

CHEST
HISTORY AND PHYSICAL EXAMINATION

Clear to P&A.

HEART
Not enlarged, regular rate and rhythm. No murmurs.

BREASTS
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 nerves II through XII intact as tested.

DISPOSITION
Admit for possible urinary bladder repair.
_________________________
Kathleen J. Lorencz, MD
OB-GYN Department

KJL: BT
D: 06/24/2018
T: 06/25/2018