I’m here for my annual exam but I might be pregnant”
HPI: 28 year old white female presents to the clinic for her annual exam. Last known menstrual
... [Show More] period was 7/27/25. She has complaints of nausea. States she stopped OCPs two months ago. She has not taken an at home pregnancy test.
PMH G1P1001
:
PSH C-section (August 2014), Oral surgery (2008)
FH Father living at 60-HTN, Mother living at 56-N/A
Brother, living at age 18-N/A
Paternal grandfather, living at 80-CAD, Paternal grandmother, living at 79-HTN,
HLD
Maternal grandfather, deceased-stroke at age 85, Maternal grandmother, living at age 80-N/A
SH Married/ non smoker/No Illicit drug use /social ETOH. Patient is an accountant at a local firm.
ROS Constitutional Denies weight loss or fever
Head Denies headache or pain
Eyes Denies tearing, pruritus, erythema, edema, exudate,
vision changes. States last eye exam 9/15/15-vision 20/20 bilateral eyes. Denies corrective lenses. Ears, Nose, Mouth, Ears: Denies pain, tinnitus, discharge. Nose: Denies Throat discharge, stuffiness, sinus trouble. Mouth/Throat:
Denies pain, lesions, or ulcerations
Neck Denies swollen glands, goiter, lumps, pain, or stiffness in the neck.
Cardiovascular Denies chest pain, murmurs, dyspnea.
Respiratory Denies cough, hemoptysis, wheezing, asthma,
bronchitis.
Breast Denies any lumps, pain, discomfort, or nipple discharge. Gastrointestinal Denies difficulty swallowing, decreased appetite,
abdominal pain. States nausea with no vomiting.
Genitourinary Denies urgency, nocturia, dysuria. GYN: denies vaginal bleeding, itching, vaginal discharge.
Musculoskeletal Denies joint pain, stiffness, backache, decreased/ painful ROM.
Integumentary Denies wounds, lesions, moles, rashes
Neurological (document if Denies memory problems, gait problems, numbness,
applicable: headache, Sz, dizziness, or weakness.
visual concerns, memory, gait, numbness, tremor, weakness)
Psychiatric (depression, Denies feelings of depression or anxiety. anxiety)
Endocrine (document if Denies thyroid problems, denies intolerance to cold or applicable: Hx of thyroid nodules, heat Hx of Temp intolerance, hair changes, polydipsia or polyuria,
weight loss vs gain)
Hematologic/lymphatic Denies bruising, anemia, denies lymph node
(bleeding, bruising, anemia, known enlargement or tenderness lymph node enlargement)
Allergic/immunologic Denies allergies. Flu vaccine taken 10/1/15, MMR,
(known immune deficiencies) dTap up to date.
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