Saturday, April 11, 2020

History and Physical Examination free essay sample

: Patient is gravada 2, para 1, abortus 1. The patient’s only child is a 15 year old daughter who lives in Texas with her grandmother. PAST MEDICAL HISTORY: Patient had a Pilonidal cyst removed. Had plastic surgery on her ear as a child. SOCIAL HISTORY: Patient is married and has 1 daughter. She works as a substitute teacher. Smokes 1 pack of cigarettes on a daily basis. Denies EtOH. Smoked marijuana last night. No IV drug abuse. Patient complains of her lower abdominal pain the past week that apparently got much worse last night by this morning was intolerable. She is also having some nausea and vomiting. Denies hematemesis, hematochezia, and melena. She has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency, urgency, and hematuria. Patient also denies arthralgias.Otherwise essentially negative. Vital signs temperature 97 degrees, pulse 53, respirations 22, blood pressure 108/60.