2. Contoso
Pharmaceuticals
Subjective Data:
Chief complain/HPI
• C/O: “I am unable to sleep for days”
• HPI: 31-year-old female c/o inability
to sleep and has been fatigue for 2
weeks.
• She verbalized amenorrhea for the
last 4 mths.
• She states she started noticing milky
discharged from her right breast as
well as abnormal facial hair.
• She also describes, headaches
oligomenorrhea with bleeding
intervals of 35 days, hypomenorrhea
and a 15-lbs weight-gain over the past
2 months.
(Bickley, 2017).
PMH/PSH
• Allergies: None
• Medication: Zolpidem 5mg once
daily.
• PMH/PSH: Menarche age 15 years,
Acne age 20 to present.
Psychotherapy age 24 to present for
anxiety and sleep disturbance.
• Family history: Mother had
menopause at age 50 with HTN,
DM2. Sister has history of infertility.
No history of PCOS.
• Social History: denies tobacco,
alcohol, or illicit drugs. Exercise 1-2
times weekly.
(Bickley, 2017).
ROS
• ROS: Negative except:
• General: gain 15-lbs in 3 months.
• HEENT: Reports headaches with fatigue.
Denies visual or hearing changes.
• Skin: Reports excessive facial hair but
denies dry skin. Reports cystic acne to
the cheeks.
• Breasts: reports milky discharged from
right breast. Denies any other changes.
No pain reported.
• OB/GYN: Menarche age 13. menses
have been every 4-6 weeks and lasted
for 6-7 days with minimal flow. G1P1. last
pap smear 1year ago. No abnormal pap
smear. Not sexually active currently but
uses a condom in the past.
(Bickley, 2017).
•
3. Contoso
Pharmaceuticals
Objective Data:
VS: WNL
SKIN: Skin appear dry, hair appears thin,
facial hair noted to the chin and upper lips.
Discoloration of skin to the neck and back.
Acne scars noted to the cheeks.
HEENT: Head normocephalic , atraumatic.
PEARL bilaterally. Nasal mucosa pink and dry.
NECK: Supple with full ROM.
Hyperpigmentation noted to neck.
CV: Prominent heart sounds, S1 and S2
normal, no masses noted. Pulses 2+ equal
on both sides. PMI normal. No peripheral
edema.
Breast: Symmetric with no masses, scant
amt of milky discharge noted from nipple
(Bickley, 2017).
RESP: No adventitious lung sounds. Good air
movement
ABDOMEN: Abdominal obesity waist
circumference is >35 inches. ABD soft and
nondistented. No organomegaly or masses.
BACK: Full Rom of spine, spine is straight
with scoliosis or kyphosis.
EXT: Right knee mild swelling. No erythema.
Not tender to palpation. Full ROM of knees
bilaterally.
NEURO: Cranial nerves II-XII intact. Motor
5/5. DTR 2+ symmetrical
(Ndefo,Eaton&Green,2013)
7. Contoso
Pharmaceuticals
References
Bickley, L. S. (2017). Bates’ guide to
physical examination and history taking
(12 ed.). Philadelphia, PA: Wolters Kluwer.
Ndefo, U. A., Eaton, A., & Green, M. (2013, Jun
26). Polycystic ovary syndrome: A review of
treatment options with a focus on
pharmacological approaches. National Library
of Medicine, 6(4), 345-355. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PM
C3737989/
