Patient Information:
Initials: F. W. Age: 14 Sex: Female Race: Caucasian
S.
CC (chief complaint): Stomachache
HPI: 14-year-old, Caucasian, female
... [Show More] presenting to the teen clinic with complaints of a
stomachache. She reports daily stomachaches for the past several weeks.
Location: Abdomen
Onset: Several weeks
Character: Dull aching
Associated signs and symptoms: Nausea and fatigue
Timing: Gradual
Exacerbating/relieving factors: Stomachaches worsen with hunger and are relieved
after eating
Severity: 5/10
Current Medications: No medications
Allergies: NKDA
PMHx: no significant medical history
Soc & Substance Hx: Student, living with her aunt and uncle. No history of tobacco, alcohol,
drugs
Fam Hx: non-contributory
Surgical Hx: no surgical history
Mental Hx: She expresses fear, anxiety and reports sleeping problems
Violence Hx: She states that her mother’s boyfriend came into her room at night and touched
her. She reports that she currently feels safe living with her aunt and uncle. There are multiple
concerns about her safety within personal, home, community, and sexual life from her past living
situation related to the comments expressed regarding her mother’s boyfriend, drug use, and
drugs found within the home.
Reproductive Hx: Last period three months ago, positive urine pregnancy test
Review of SystemsGENERAL: Denies recent fever, chills, or night sweats. No recent weight gain or loss of
significance.
HEENT: Denies headache, change in vision, and problems with chewing or swallowing.
SKIN: Denies rashes, itching, lesions, open sores, or bruising. Denies history of skin cancer.
CARDIOVASCULAR: Denies chest discomfort, palpitations, edema or heart murmur.
RESPIRATORY: Denies dyspnea, cough, sputum production, or hemoptysis.
GASTROINTESTINAL: Complaints of stomach pain for several weeks, accompanied with
nausea. Denies diarrhea and constipation.
GENITOURINARY: No change in urinary pattern. Denies dysuria or incontinence [Show Less]