Discussion: Allergies to food or medication

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.

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.

 

Family History

Mother: Alive, Diabetes type II.

Father: Alive, High cholesterol, CAD.

Sibling: 1 Sister, Healthy.

 

Children: 1 Healthy.

 

 

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

ROS

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.

 

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