Get Answer: History Present Illness Question Guide

This question focuses on applying theory to practical scenarios.

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This question relates to history present illness and requires a structured academic response.

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Focus on explaining concepts clearly and supporting them with examples.

Key Explanation

This topic involves history present illness. A strong answer should include explanation, application, and examples.

Original Question

History of Present Illness (HPI): Lucy, a 64-year-old G3P3003 postmenopausal woman, presents to the office as a new patient to establish care and for an annual well woman exam after recently moving to the area. She does not have her records. She relates a history of regular and negative cervical cancer screening until she had her first cotest 2 years ago indicating HPV positive, cytology negative results. She c/o vaginal dryness and dyspareunia. She has never been on hormone replacement therapy but would consider something to alleviate her symptoms. Prior medical history: Dyslipidemia, Osteopenia, Hypothyroidism, Uterine fibroids Prior surgical history: Hysterectomy – ovaries and cervix retained (2009) Current medications: rosuvastatin 10mg daily, levothyroxine 75mcg daily, Vitamin D3 (k2) 5,000 IU daily Allergies: Sulfa, Codeine OB- GYN History: NSVD x 3 (1980, 1983, 1989) healthy female 6lb 8oz; healthy female 7lbs 6oz; healthy male 6lb 6oz. Menarche age 13, normal periods. No history of sexually transmitted infections (STDs). LMP: Hysterectomy 2009. Contraception history: Never used. Social history: Lives alone. Recently moved to the area after her husband of 45 years passed away. Plays pickle ball 3 times/week. Healthy diet. Never smoked. ETOH – 1 glass wine/ nightly. Family history: Mother deceased (age 62)- breast cancer. Father deceased (age 70)- CVA, leukemia. Review of Systems (ROS): Unremarkable with exception of as noted in HPI. Physical Exam (PE) VS: BP: 130/78, P: 78, RR: 18, T: 98.1 Weight: 152 lbs., Height: 67″, BMI 23.8 General: Awake, Alert, Oriented x 3. Well developed, well nourished. Pleasant. Integumentary: Warm, dry, and intact. No lesions, rashes, or bruises. Abdomen: Soft, NTND, BS present x 4. Surgical scar noted. External: Grey sparse hair distribution, atrophic changes noted. Speculum exam: No discharge, no lesions, multiparous cervix. Bimanual exam: uterus surgically absent, No adnexal masses palpated bilaterally, nontender. Breast exam – left breast with walnut size mass palpated at 9 o’clock position. Nontender. Right breast normal exam. No nipple discharge.

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