Helen McDonald 9/17/09 Family Health History Review of Systems H.G. D !

10/"#/1977 FH$ %t&s father a '( yr old) only child) with a history of hy*ertention) rhe+matoid arthritis) enlar,ed heart and o-esity. %t&s mother is '1 yr old with a history of o-esity. %ts mother was ado*ted. %t has a .. yr old sister and a -rother who is .0 yrs old. !oth si-lin,s are alive and well. %t is married to a .( year old male who is alive and well. %t has three children/ a one yr old male) a fo+r yr old female) and an ei,ht yr old male. 0ll three children are alive and well. %t denies family history of heart disease) dia-etes) cancer and stro1e. 2D$ %t is at ris1 for o-esity) H32) R0) and enlar,ed heart r/t family history 04! ,eno,ram. Review of systems S1in) Hair) 2ails$ %t states she had shin,les three months a,o. 3he shin,les she states) affected her rt 5aw and down the -ac1 of her ri,ht lateral side of her nec1. Sym*toms of rash and itchin, lasted one wee1. %t states she has Melasma. %t states she has had red discoloration to -ilateral chee1s. 3his -e,an with her third *re,nancy d+rin, her second trimester and contin+es to date. %t states she has had -asil cell carcinoma to her left chin) which she had removed in 6an+ary of "00' needin, no f+rther intervention. %t denies hair loss) sweatin, or dandr+ff. Head and 2ec1$ %t states she has had infre7+ent headaches occ+rrin, once every "8. 9ee1s. %t states headaches are associated with nasal con,estion. %t denies nec1 stiffness) diffic+lty swallowin, and enlar,ed lym*h nodes. 4ars$ %t states she s+ffered from chronic ear infections as a child. %t denies c+rrent ear *ain) rin,in,) -+::in,) draina,e) diffic+lty hearin,) e;*os+re to lo+d noises or di::iness. 4yes$ %t com*lains of intermittent) itchy) watery eyes and -l+rred vision. %t denies *ain) halos) -lac1 s*ots) flashes or do+-le vision. Mo+th) 3hroat) 2ose) and Sin+ses$ %t states she has had intermittent sym*toms of st+ffy nose with small amo+nts of clear nasal draina,e. %t states her sym*toms -e,an a-o+t ".' months a,o. %t states o+tdoor activities a,,ravates her sym*toms. %t has -een +sin, over the co+nter !enadryl that relieves her sym*toms. %t states she has had a history of fre7+ent nose-leeds as a child. %t states she still has her tonsils. %t denies mo+th *ain) sore throat) lesions) hoarseness) co+,hin,) and snorin,.

3hora; and <+n,s$ %t denies *ain) diffic+lty -reathin,) S !) D 4) ortho*nea) co+,h) s*+t+m *rod+ction) and res*iratory infections. !reasts and Re,ional <ym*hatics$ %t states she is c+rrently -reastfeedin,. %t denies -reast or ni**le *ain. %t *erforms self -reast e;aminations monthly. %t last -reast e;am was 0+,+st "00#. %t denies havin, a mammo,ram. %t denies l+m*s) dim*lin, or tenderness to lym*h nodes in a;illa. Heart and 2ec1 =essels$ %t denies chest *ain or *ress+re) *al*itations) edema. %eri*heral =asc+lar$ %t denies le, or feet *ain) swellin, and sores. 0-domen$ %t denies a-dominal *ain) na+sea and vomitin,. %t denies chan,es in -owel ha-its. %t states she has one to two formed -owel movements daily. Female Genitalia$ %t states her first menses was on her 1"th -irthday) 10/"#/#9. %t denies *elvic *ain) voidin, *ain) diffic+lty +rinatin,. %t had three +ncom*licated va,inal deliveries. %t denies any a-ortions or miscarria,es. %t denies history of S3Ds. %t denies -irth control +se. 3he *atient has had three va,inal deliveries with no com*lications with *re,nancies or -irth/ (/#/01) 10/"./0() #/11/0#. %t is ,racida .) *ara .. 0ller,ies$ %>2 Reaction ca+sed a ,enerali:ed rash.