K. F., 37 y.o. female
S.
CC. Well Women Exam
HPI: Kayla reports that she is healthy and takes no medication. She has no symptoms that she
can think of other than she is currently having trouble falling and staying asleep, but associates
this with stress and with sleeping in the same room with her two younger children. She is a 15-
year smoker of 1PPD up until 18 months ago when she quit with the pregnancy of Riley. She is
concerned about finances today and reports ongoing fatigue. She has not and menses since the
birth of her last child. She is not currently sexually active with men, women, or both and has
been abstinent for the last 6 months.
PMH: Kayla denies any past medical history other than four pregnancies, three births, one pre-
term, and two C-sections with the last two births. She had one miscarriage at 10 weeks when she
was 16. She also reports that she had PCOS as a teenager and has always had irregular menses.
She had gestational diabetes with the last birth and preeclampsia causing the early delivery of
Riley.
Current Medications: She is currently taking Advil PM every night to sleep
Surgeries: Denies any surgeries except two C-sections.
Allergies: She has no allergies.
Vaccine History: Unknown. When was you last flu vaccine?
Social History: She is a 15-year smoker of 1PPD up until 18 months ago. Drinks a glass of wine
at night. She does not routinely exercise. She often skips breakfast and lunch and eats whatever
the children eat for dinner, which is often processed, or quick food.
Family History: Kayla’s mother has a history of hyperlipidemia, Type 2 DM, glaucoma, breast
cancer at age 50 treated with lumpectomy, and Hypertension. She is Latin American in descent,
emigrating from Cuba in the 1970s. Kayla’s father has a history of hypertension, hyperlipidemia,
and an MI with stenting 5 years ago. The mother has two siblings; a younger brother in the U.S.
Navy, and an older sister who is 42 and lives in a large urban city in the Midwest with her
family, and she is in good health. Other family members died of old age. She is unaware of
paternal familial health history.
ROS:
Constitutional-Reports ongoing fatigue, trouble falling asleep and staying asleep.
HEENT-Not reported
Skin-Not reported
Cardiovascular-Not reported
