Sonya Phillips
23 year old
5’ 9” 121 lb
CC Abdominal pain
Visual: Ill appearing, grimaces with any movement. Sitting still and uncomfortably.
... [Show More] Minimizing
movement.
Skin: warm moist
How can I help you today? Ive had this pain in my lower abdomen for 5 days, pretty mild pain (points to
suprapubic region). Then yesterday it seemed to move to my left lower side in the pelvis (points to
LLQ/pelvis) and it has been getting worse and worse.
Are there any othersymptoms we should discuss? Yeah. Now Im feeling sweaty, I have chills and also fell
kind of nauseated and lightheaded.
Does anything make the pain in your abdomen better or worse? Same as for the pain in my pelvis
What does the pain/discomfort in your abdomen feel like? (cramping burning,stabbing, aching, tingling,
squeezing) It was sort of achy when it started in my abdomen, but now its really more in my pelvis.
Do you have any vaginal discharge/discomfort? Yes I do, it is kind of nasty.
What is the appearance, smell, texture and quantity of the vaginal discharge? I don’t know how to
describe it, but it smells pretty strong and smelly to me. Its nasty.
Is there vaginal discomfort or itching? No
When did your vaginitis/vaginal discharge start? It started around the time my abdomen started to hurt
What treatments have you had for your vaginal discharge/ discomfort? You mean in the past or now?
Nothing for this yet. I didn’t try any monistat or anything like that.
Have you had vaginal discharge/discomfort like this before? No. I don’t think so. Well maybe it is sort of
like the stuff that came out when I had chlamydia a few years ago. This seems worse or different
somehow.
Do you have any genital sores or discharge? No
Have you inserted any foreign bodies into your vagina? no
What does your pelvic pain feel like? It started out feeling kind of dull and achy. It was more in my
abdomen then. Now it feels like an intense boring pain on that one side.
Does anything make your pelvic pain better or worse? Um standing on my job as a cashier for a long time
has been a killer-totally worse. My job as a cashier you know on my feet all day really makes it so bad I
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had to leave work. Yesterday I took the whole day off and laid on the couch. I thought I could manage
work today but I had to leave after just an hour. The pain was so bad. No just about any movement and
walking around is really bad. Nothing makes it better. That’s why I came here.
Is your pelvic pain superficial or deep inside? It feels like its inside, deep in there.
Do you have pain/discomfort when you are at rest? Yes, the pain is there when Im resting too.
How severe is your pelvic pain? Its bad, id say maybe like 8 or 9
Does your pelvic pain radiate someplace else? No it doesn’t radiate anywhere, it did move from the
middle area to here though (LLQ)
Does your pelvic pain keep you from sleeping? NO
Have you had pelvic pain before? no
Is there a pattern to your pelvic pain? No, its been constant since it stated 5 days ago.
Do you have pain or discomfort when you urinate? No
Is your urine pink or red in color? No, and none when I poop either
Have you been having fevers? No. Funny, I haven’t had a fever but I have had chills and sweats.
Do you have nausea and or vomiting? Yeah, the past 2 days Ive been nauseated, no vomiting though.
How severe is your nausea or vomiting? Not too bad
Do you feel lightheaded? Yes I have been feeling lightheaded.
When did your lightheadedness start? About 2 days ago, along with the nausea
Does anything make your lightheadedness better or worse? Not really
Have you ever lost consciousness after being lightheaded? no
Are you having any problems with your periods? Even though im on the pill, I still have a lot of cramping
around my period. They said it would go away, but it hasn’t.
How regular are your periods? Theyre regular
Do you have bleeding between your menstrual cycles? no
How many tampons or pads do you use daily? maybe 3
When did you last period start? Three weeks ago. Pretty easy to keep track of on the pill.
Have you recently missed or stopped taking your birth control or hormone pills? No im careful about
taking them
Is it possible that you are pregnant? no
Tell me about any current or past medical problems? Nothing much really. I had to take antibiotics a
couple years back. That’s about it
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Have you had any sexually transmitted disease? Chlamydia, 3 years ago. But they said it was completely
cured.
Have you had any recent infection? No the last infection was 3 years ago.
Do you engage in vaginal douching? No
Have you had any trauma to your abdomen? No
Have you had any trauma to your pelvis? Same as I told you about my abdomen. Didn’t I tell you about
that?
Have you ever had any abdominal surgery? No
Any previous medicalsurgical or dental procedures? no
Have you ever been hospitalized? no
Any allergies? No
Are your immunizations up to date? Yeah and I had the HPV vaccination a year ago.
Have you had a flu shot? Yes
Have you had a meningococcal vaccine? Why do you need to know that?
Are you taking any prescription medications? Just the birth control
Are you taking any OTC or herbal medications? No
When and what was the result of your last gynecological exam? Not that long ago. It was normal
Have you ever had a pap smear? Yes
Have you had PID? no
Do you drink alcohol? How much? I drink socially, when I go out. I go out maybe 2 or 3 times a week. Ill
have maybe 4 to 6 drinks. That’s it.
Do you use any recreational drugs? no
Do you smoke? no
Are you sexually active? yes
At what age did you become sexually active? Why do you need to know tha [Show Less]