assessment

Case 1

Case 2

Case 3

Subjective Data

Chief Complaint (CC)

“I am here for my annual physical exam and have been having vaginal discharge.” 

History of Present Illness (HPI)

32-year-old pregnant lesbian – her pregnancy has been without complication thus far. She has been receiving prenatal care from an obstetrician. She received sperm from a local sperm bank.

PMH

PSH

Drug Hx

Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion

Allergies

Family Hx

She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.

Review of Systems (ROS)

 General

No fatigue, fever, or chills.

Head, Eyes, Ears, Nose & Throat (HEENT)

 Neck

 No pain or injury

 Respiratory

 CV

GI

GU

Integument

multiple piercings, and tattoos. Old scars related to “cutting”

MS/Neuro

no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.

 PE

B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98

 General

 HEENT

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.

 Lungs

CTA AP&L

Card

S1S2 without rub or gallop

Abd

benign, normoactive bowel sounds x 4

GU

external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact.

Ext

no cyanosis, clubbing or edema

Integument

intact without lesions masses or rashes.

MS

Neuro

No obvious deficits and CN grossly intact II-XII