SUBJECTIVE DATA:
General patient information
This is a comprehensive assessment on a 21-year-old female, African American that has mixed
ethnicity, her mother is a white and her father is an African American. She is
...
SUBJECTIVE DATA:
General patient information
This is a comprehensive assessment on a 21-year-old female, African American that has mixed
ethnicity, her mother is a white and her father is an African American. She is single and lived with her
mother, father, and her brother. G1 T0 P0 A0 L0.
Chief concern/complaint (CC) and history of present illness (HPI)
AA is a 21-year-old African American female, sexually active, G1PO visited the health care center
today with complains of vulvar itching, vaginal discharge, and pelvic pain started 7days ago. She
complains that the pelvic pain gets worst and describes pain as “come and go shooting pain”, when she
urinates or having a sexual intercourse. AA reported the pain scale as 7/8 during urination and 9/10
during intercourse. AA verbalized the aggravating factor to be a vaginal discharge that is constant, severe
and describes the color as thick, copious mucous frothy foul smelling yellow-green discharge. AA
verbalized taking OTC medications Ibuprofen 400mg every 6 hours as needed and used vaginal cream for
yeast infection to relieve the itching but the itching and the pain are not relieved. AA verbalized this kind
of health problems had happened during my first week first trimester and the doctor called it
Trichomoniasis, got treated with my partner. AA last menstrual period was July 15, 2019 and using the
Nagele´s rule, which is to add 7 days to the first day of the menstrual period, then subtract 3 months it
will calculate the estimated due date, which will be April 22, 2020 (Schuiling & Likis, 2017).
AA verbalized not exposed to Diethylstilbestrol (DES) and neither was her mother.
Diethylstilbestrol (DES) was utilized between 1940 and 1971 as an artificial formula of estrogen to
prevent miscarriages, preterm labor, and complications during pregnancy but has indicated to cause
clear cell carcinoma (Diethylstilbestrol (DES) and Cancer, 2011).
AA is currently sexually active with males, and has multiple relationship but now not in good
relationship with her baby’s father and had not seen him after being aware of her pregnancy. AA denies
using any contraception or protective barrier devices such as female condoms or male condoms to
prevent sexually transmitted diseases (STDs).
Patient Past history/PMHx: The patient has past medical history of Asthma, HTN, Obese, Pre-DM,
trichomonas’s treated in the past, and a scar on her forehead from a piece of glass through car accident
that occurs when she was four years. Psychological and mental health is imbalance due to AA father
verbally abused her and her neighbor sexually abused her but no reports filed. AA reports being bullied a
lot due to her overweight and poor dressing habit as a result of poverty. AA denies any surgeries or
hospitalizations.
Family medical history: AA mother has past medical history of hypertension and Asthma but denies any
other family history of breast cancer, colon cancer, and cervical cancer. Other family history is unknown,
verbalized that she does not known much about other family members.
Medications: AA is taking OTC Ibuprofen 400mg 1-tab PO BID as needed for her pelvic pain and OTC
vaginal cream for itching but cannot remember the medication name. Hydrochlorothiazide 25 mg 1 tab
PO QD prescribed for her hypertension, but patient verbalized not taking the blood pressure medication.
Flagyl 500mg 1tab PO BID for 7 days – positive for trichomoniasis (completed and resolved). Albuterol
inhaler 2 puffs orally inhaled every 6 hours as need for Asthma. The patient verbalized used it once in a
while as needed. She has no known allergy to medications, foods, and environment.
AA Health maintenance/screenings such as childhood immunization are up-to-date and she did not take
the Gardasil immunizations. She had chickenpox in her 4th grade, even though she had vaccination. She
was screen for rubella and is immune to rubella. She refuses to take to the flu vaccine and stated “it
makes me sick every year”. She had never had a pap smear done. She denies any surgeries or
hospitalizations.
Gynecologic history: The patient verbalized that her periods started at the age of 11, was always regular
occurs every 28 days but runs 5 days long, but very heavy used 5 pads a day throughout the whole cycle.
She has a positive history of trichomoniasis, which she verbalized that she took all prescribed
medications earlier in the pregnancy but since she is sexually active 4 to 5 times a week and has multiple
partners for intercourse without protection it is possible that she may have been exposed to the STD
again. She is nulligravida one para 0, term 0, Labor 0, Spontaneous abortion-0 (G-1, T-0, P-0, A-0, L-0).
The patient never given birth to any child before, no term delivery, no pre-term deliveries, no
spontaneous abortion or miscarriage or induced abortions and no living children.
Personal social history: AA is an African American single female that lived with the parent and brother in
a one-story town house with smoke alarm already paid in full by the grandma. She is from poor family
background. Patient denies living near any factory plants that may produce harmful smoke to her or to
the fetus (Schuiling & Likis, 2017). She dropped out of school after high school due to inadequate funds,
unemployed and family incomes are in poor economic condition. She does wears seatbelt in the car
when receiving a ride from a friend. She has Medicaid insurance and a link card for foods. She is
currently unhappy and has unplanned pregnancy stated that her boyfriend left after finding out she was
pregnant. She denies being current physically or verbally abused or forced sex by her boyfriend. She
verbalized only being sexually abused once by her neighbor which she never made a report long time
ago. She is obese at 285 lbs. and breathes heavily during communication. My preceptor mentioned that
the patient was instructed and encouraged to lose weight several times to control her diet and exercise
due to her BMI is 44. The patient verbalized that she hates doing any physical activity and exercise
because it caused her body pain. Also, she complains that when she is stressed out she hates to cook
and eats a lot of fast food to control her stress. She verbalized sleeping only five hours in the night and
complains of insomnia sometimes. The patient appears poor grooming and hair unkempt. She was
unable to remember the last dental visit or last checkup for her health routine. She smokes two sticks of
cigarettes a day for three years plus and stop after she found out she was pregnant. She denies drinking
alcohol while pregnant but used to drink 3 bottles of beer and a glass of vodka twice a week. Also, the
patient denies using illicit drugs but her Urine drug screen indicates positive for THC. She denies taking
any caffeine but like drinking coke and Pepsi a lot which contains caffeine. According to one prospective
cohort study, indicates that the risk of spontaneous abortion was found to be higher in women who
consumed > 300 mg of caffeine a day (Hahn, et al., 2015).
Review of Systems (ROS):
General: AA Overall health, weight gain, obese, poor grooming hygiene and denies any distress.
Skin: AA denies any skin rashes or lesions and no itching or any color discoloration.
HEENT: AA denies any headache; no blurred vision, no redness, last vision screening or eye
exam is unknown. No hearing loss, discharge, obstruction, epistaxis no nosebleed and no sore
throat.
Neck: Denies any tenderness or lymph nodes.
Breasts: AA reports breast tenderness and leakage of colostrum. Breast: practice of self-breast
exam, She denies any lumps or masses.
Respiratory: AA denies any SOB, no wheezing, no night sweats and no respiratory distress
Cardiovascular: AA denies any chest pain, no murmur and heat problem.
Gastrointestinal: AA reports pelvic pain, burping and stomach acid reflux, denies any nausea and
vomiting.
Peripheral vascular: AA complains of legs swollen during the day but denies any pain.
Genitourinary: AA complains of urinary frequency, urgency, and burning with urination. Also
complains of sexual difficulty, and venereal disease. 20 weeks gestational pregnancy ( G-1, T-0, P0, A-0, L-0). LMP- 7/15/2019, EDD-4/22/2020, contraceptive use- None, last pap smear not done
Reproductive system/Genital: AA complains of vaginal discharge and vaginal itching, pain
during intercourse
Musculoskeletal: AA denies any muscle weakness or tenderness no joint pain and no back pain.
Psychiatric: AA denies any nightmares; mood change, depressions anxiety, nervousness,
insomnia, suicidal thoughts, potential for exposure to violence
Neurological: AA denies any muscle weakness, syncope, stroke, seizures, paresthesia,
involuntary and no change in level of consciousness no movements or tremors, and no severe
headaches.
Hematologic/ lymphatic: AA denies any bruising or abnormal bleeding, no fatigue, no history of
anemia or blood transfusions, and no swollen or tender glands.
Endocrine: AA denies any thyroid problems, cold or heat intolerance, polydipsia, polyphagia,
polyuria, changes in skin, hair or nail texture, unexplained weight change, and changes in facial
or body hair. Denies any use of hormonal therapy.
Allergic/immunologic: AA denies any seasonal allergies, no previous allergy testing, no potential
for exposure to blood and body fluids, immunized for Hep B, no immunosuppression in self or
family member, and no use of steroids.
OBJECTIVE DATA:
Physical exam:
Vital Signs: BP- 148/82, HR- 92 R-18, T- 98.4, SpO2 100% RA. Ht 5”6 Wt. 285 lbs, BMI-44
General: AA appears sad, affect flat, in poor grooming and hair unkempt.
SKIN: AA Skin is intact warm and dry to touch, no bruises or cuts.
HEENT: AA is normacephlac, no blurred vision, no hearing loss, no nosebleed, and no sore throat
Neck: AA has no cervical adenopathy
Breasts: AA breast is bilateral symmetrical, nipples symmetrical and everted
Chest/Lungs: Lungs clear to auscultation, no wheezes or rales, no rhonchi. Regular heart rhythm, no
chest pain
Heart/Peripheral Vascular: S1, S2 normal, no murmur or no gallop
Gastrointestinal : obese, fundal height 22 almost consistent with her 20 weeks gestational pregnancy.
Linea Ingra is present. Doppler used to listen for Fetal heart tones (FHT) is normal and fetal heart rate
(FHR) at 155. Fetal movement is positive.
Reproductive system/Vaginal: vaginal rugea is reddened and inflamed with irritation, cervix seen
through the speculum is pink, cervix is closed, and thick, light, green discharge is seen.
Musculoskeletal: Slight plus one edema noted on both bilateral feet but able to move all extremities.
Neurological: AA level of consciousness is normal and no abnormalities noted.
Psychiatric: AA affect is flat, mood low; sad denies feeling depressed no suicidal ideation
Hematologic/ immunologic: No bruising or abnormal bleeding, no fatigue, no swollen glands noted.
Labs, tests, and other diagnostics
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