HISTORY AND PHYSICAL EXAMINATION

PATIENT NAME: Christina Youngblood

PATIENT ID: 712102

ROOM NO.: 418

DATE OF ADMISSION: Kathleen J. Lorencz, MD

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.

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.

(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