Discussion: Allergies to food or medication
Discussion: Allergies to food or medication
CC: “I had been pelvic pain irradiated to the back with my prolong menstrual period.”
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HPI: Patient is a 30-years-old female presents to the office with pelvic pain irradiated to the back, irritability with her prolonged menstrual period. |
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Medications: No. | |
PMH: Denies
Allergies: Denies any allergies to food or medication Medication Intolerances: Denies. Major traumas: Denies any trauma Hospitalizations: Denies hospitalizations Surgeries: Appendicectomy 2014.
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Family History
Mother: Alive, Diabetes type II. Father: Alive, High cholesterol, CAD. Sibling: 1 Sister, Healthy.
Children: 1 Healthy.
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Social History:
Home type: Apartment. Marital status: Married. Religion: Catholic. Tattoos: no Alcohol: wine 1-2 cup only weekends. Drugs: Denies any Drugs consumption. Smoker: Non-smoker Exercise: 30-45 minutes of walk 3 times a week Travel: Denies. Blood Transfusion: Denies OBSTETRIC/GYNECOLOGICAL HISTORY: married, sexually active, Heterosexual, denies STI’s, Menarche: at age of 11. LMP: 11/24/2018. 28 for 5 days, regular cycle, G1T1P1A0L1. Birth Control: Yes/ IUD. One partner |
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General
Denies any weight change in the last past 6 months denies weakness, fatigue report monthly. No distress noted at this moment, responding question in an appropriated mood. No exercise intolerance. |
Cardiovascular
Patient denies chest pain and palpitation. No edema noticed no syncope, no orthopnea. |
Skin
Warm and dry, skin is appropriated color for ethnicity. |
Respiratory
Patient denies cough, dyspnea, wheezing or hemoptysis, no acute distress at this moment. |
Eyes
Denies changes in vision, no blurred vision, no diplopia, no tearing, no scotomata, and no pain. |
Gastrointestinal
No nauseas, no emesis, no dysphagia, no bowel habit changes, no melena, no constipation. |
Ears
Denies ear pain, hearing loss, ringing in ears, discharge, pearly grey membranes. |
Genitourinary/Gynecological
Report dysuria, frequency or urgency. Denies blood in urine. No urinary urgency, no change in nature of urine. Heavy irregular vaginal bleed. OBSTETRIC/GYNECOLOGICAL HISTORY: married, Sexually active, Heterosexual, denies STI’s, Menarche: at age of 11. LMP: 11/24/2018. 28 for 5 days, regular cycle, G1T1P1A0L1. Birth Control: Yes/ IUD. One partner. |
Nose/Mouth/Throat
Denies difficulty in smelling, sinus problems, nose bleeds or discharge. Denies dysphagia, hoarseness, or throat pain. |
Musculoskeletal
Denies cramps, joint stiffness, arthritis or gout, limitation of movement, history of musculoskeletal or disk diseases; denies any muscle or joint pain. |
Breast
Denied nipple discharge, breast pain or change in the breast skin. |
Neurological
Denies history of headaches, syncope, seizures, stroke, memory disorder or mood change. No weakness, paralysis, numbness/tingling, tremors or tics, involuntary movements, or coordination problems. No mental disorders or hallucinations. |