妊娠检查标准英文病历.docxVIP

Note for Jane Doe on 4/10/02 - Chart 5407 CHIEF COMPLAINT (1/1): This 32 year-old female presents today for an initial obstetrical examination? Home pregnancy test was positive? The patient indicates fetal activity is not yet detected (due to early stage of pregnancy). LMP: 02/13/2002 EDD: 11/20/2002 GW: 8.0 weeks. Patient has been trying to conceive for 6 months. Menses: On set: 12 years old. In terval: 24-26 days. Du rati on: 4?6 days ? Flow: moderate ? Complications: PMS - mild. Last Pap smear taken on 11/2/2001. Contraception: Patient is currently using none. Allergies: Patient admits allergies to venom - bee/wasp resulting in difficulty breathing, severe rash, pet dander resulti ng in nasal stuffin ess ? Medication History: None. Past Medical History: Past medical history is unremarkable? Past Surgical History: Patie nt admits past surgical history of ton sillectomy in 1980. Social History: Patient admits alcohol use Drinking is described as social, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use. Family History: Patient admits a family history of cancer of breast associated with mother. Review of Systems: Neurological: (+) unremarkable, Respiratory: (+) difficulty sleeping, (-) breathing difficulties, respiratory symptoms, Psychiatric: (+) anxious feelings, Cardiovascular: (-) cardiovascular problems or chest symptoms, Genitourinary: (-) decreased libido, (-) vaginal dryness, (-) vaginal bleeding. Diet is high in empty calories, high in fats and low in fiber. Physical Exam: BP Standing: 126/84 Resp: 22 HR: 78 Temp: 99.1 Height: 5 ft. 6 in. Weight: 132 lbs. Pre-Gravid Weight is 125 lbs. Patient is a 32 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus? Oriented to person, place and time? Mood and affect normal and appropriate to situation. HEENT:Head Face: Exami nation of head and face is un remarkable Skin: No