HISTORY AND PHYSICAL EXAMINATION

PATIENT NAME: Christina Youngblood

PATIENT ID: 712102
ROOM NO.: 418
DATE OF ADMISSION: 06/24/XX
ADMITTING PHYSICIAN: 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 two 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; Christina Youngblood
Patient ID: 712102
Date of Admission: 06/24/XX
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: 6 cm 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: cs
D: 06/24/XX
T: 06/25/XX