Assessment 1: High Risk Pregnancy
Subjective Data is M.J. is a 24-year-old African American female who presented the clinic for abnormal vaginal bleeding and twelve weeks pregnant. The patient is a single mother who works as a cashier clerk, has a high school level of education, and lives with her boyfriend of one year. She denies a history of alcohol or drug abuse. M.J. admits to being pregnant since using a home pregnancy test. M.J. states that she may be 12 weeks pregnant and denies having any prenatal testing.
History of present illness, M.J. called this morning and needed to be seen, she was advised to go the ER, which she refused. M.J. was interviewed today and complains that she began to notice a small amount of blood for one week. …show more content…
Denies delayed healing, rashes, bruising, bleeding, or changes in lesions or moles; Respiratory: Denies cough, wheezing, or dyspnea; Eyes: Denies visional changes or blurry vision; Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, or loss of appetite; Ears: Denies ear pain, hearing loss, fluid, or ringing in ears; Nose/Mouth/Throat: Denies sinus problems, dysphagia, epistaxis, or discharge; Breast: Denies lumps, bumps, or changes in her breasts. Occasionally performs monthly self-breast exam; Genitourinary/Gynecological: Complains of a white creamy vaginal discharge with odor. Denies urgency, frequency, dysuria, or urinary incontinence. Denies history of STIs. Admits to multiple sex partners within the last six months with occasional condom use. LMP: 11/01/2015, menstrual cycle x 3 days with no heavy bleeding; Musculoskeletal: Denies joint or back pain, stiffness, or family history of osteoporosis; Neurological: Denies syncope episodes, seizures, paralysis, parethesis, or weakness; Heme/Lymph/Endo: Denies HIV testing or known status, previous blood transfusions, swollen glands, increased thirst, or intolerance to heat or cold; Psychiatric: Denies suicidal ideation, mood swings, …show more content…
M.J. is a healthy, clean, well dressed female with no acute distress noted; She is alert & oriented x four, is able to answer questions appropriately, and has a good disposition; Skin: warm, dry, clean, and intact, no rashes or lesions noted, mucous membranes moist and intact; HEENT: Head is normocephalic and without lesions; hair evenly distributed; Eyes: PERRLA, EOMs intact, no conjunctival or scleral injection; Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized; Nose showed that the nasal mucosa is pink; normal turbinate’s and septal deviation; Neck is supple; Full ROM; no cervical lymphadenopathy; no occipital nodes; no thyromegaly or nodules; Oral mucosa pink and moist. Pharynx is no erythematous and without exudate. Teeth are without previous dental extraction and she visits the dentist once a year; Cardiovascular showed S1 and S2 with regular rate and rhythm, no extra sounds, clicks, rubs, or murmurs, capillary refill less than 3 seconds. 2+ extremity pulses with no edema noted; Respiratory showed lungs symmetrical to the chest wall. Respirations even, regular and no distress; lungs clear to auscultation; Gastrointestinal: BS x 4 quadrants, active, abdomen soft,
Subjective Data is M.J. is a 24-year-old African American female who presented the clinic for abnormal vaginal bleeding and twelve weeks pregnant. The patient is a single mother who works as a cashier clerk, has a high school level of education, and lives with her boyfriend of one year. She denies a history of alcohol or drug abuse. M.J. admits to being pregnant since using a home pregnancy test. M.J. states that she may be 12 weeks pregnant and denies having any prenatal testing.
History of present illness, M.J. called this morning and needed to be seen, she was advised to go the ER, which she refused. M.J. was interviewed today and complains that she began to notice a small amount of blood for one week. …show more content…
Denies delayed healing, rashes, bruising, bleeding, or changes in lesions or moles; Respiratory: Denies cough, wheezing, or dyspnea; Eyes: Denies visional changes or blurry vision; Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, or loss of appetite; Ears: Denies ear pain, hearing loss, fluid, or ringing in ears; Nose/Mouth/Throat: Denies sinus problems, dysphagia, epistaxis, or discharge; Breast: Denies lumps, bumps, or changes in her breasts. Occasionally performs monthly self-breast exam; Genitourinary/Gynecological: Complains of a white creamy vaginal discharge with odor. Denies urgency, frequency, dysuria, or urinary incontinence. Denies history of STIs. Admits to multiple sex partners within the last six months with occasional condom use. LMP: 11/01/2015, menstrual cycle x 3 days with no heavy bleeding; Musculoskeletal: Denies joint or back pain, stiffness, or family history of osteoporosis; Neurological: Denies syncope episodes, seizures, paralysis, parethesis, or weakness; Heme/Lymph/Endo: Denies HIV testing or known status, previous blood transfusions, swollen glands, increased thirst, or intolerance to heat or cold; Psychiatric: Denies suicidal ideation, mood swings, …show more content…
M.J. is a healthy, clean, well dressed female with no acute distress noted; She is alert & oriented x four, is able to answer questions appropriately, and has a good disposition; Skin: warm, dry, clean, and intact, no rashes or lesions noted, mucous membranes moist and intact; HEENT: Head is normocephalic and without lesions; hair evenly distributed; Eyes: PERRLA, EOMs intact, no conjunctival or scleral injection; Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized; Nose showed that the nasal mucosa is pink; normal turbinate’s and septal deviation; Neck is supple; Full ROM; no cervical lymphadenopathy; no occipital nodes; no thyromegaly or nodules; Oral mucosa pink and moist. Pharynx is no erythematous and without exudate. Teeth are without previous dental extraction and she visits the dentist once a year; Cardiovascular showed S1 and S2 with regular rate and rhythm, no extra sounds, clicks, rubs, or murmurs, capillary refill less than 3 seconds. 2+ extremity pulses with no edema noted; Respiratory showed lungs symmetrical to the chest wall. Respirations even, regular and no distress; lungs clear to auscultation; Gastrointestinal: BS x 4 quadrants, active, abdomen soft,