Name: L.V Date: 29th August, 2020
Time: 0900 Hrs
Age: 16 years
Sex: Female
SUBJECTIVE
CC: The patient reports of having vaginal bleeding and UCG, abdominal pain and pelvic pain with some unusual vaginal discharge 2 weeks after having unprotected sex.
HPI: The patient is G1P0 and is currently 4 weeks + 5 days pregnant by the last menstrual period (LMP) of 15/8/2020. She had home pregnancy test four days ago. She denies any nausea and is reporting a mild breast tenderness. She has vaginal bleeding and some unusual discharge following the unprotected sexual intercourse of two weeks ago. She reports of large amount of the yellowish to white vaginal discharge with no odor and she is currently wearing a pad. The discharge started one to two weeks ago. She never experienced any pain during her last sexual intercourse. There was no itching nor burning sensation. She denies of any previous discharge (Elwell et al., 2016).
Medications: She is under no medication at present
PMH: she denies the history of major illness, injuries, blood transfusion, or hospitalization. She is capable of performing her ADLs successfully.
Allergies: NKDA
Medication Intolerances: No medication intolerance
Chronic Illnesses/Major traumas: denies any history of chronic disease or major traumas. She has not been diagnosed with hypertension, diabetes, asthma, lung disease, Tuberculosis, or cancer.
Hospitalizations/Surgeries: denies any history of hospitalization or any surgical procedure
Family History: The mother is a live and has history of hypertension. Her maternal grandfather is having a history of adult-onset of diabetes mellitus.
Social History: she is living with her parents in a local community and she has no job. She has made an attempt to apply for the WIC and the Medicaid benefits last week after learning about her pregnancy. She is currently single with no man to specify as her boyfriend. She denies of any abusive environment (Witkin, Minis, Athanasiou, Leizer , & Linhares , 2017).
ROS