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1、NoteforJaneDoeon4/10/02-Chart5407CHIEFCOMPLAINT(1/1):This32year-oldfemalepresentstodayforaninitialobstetricalexamination・Homepregnancytestwaspositive・Thepatientindicatesfetalactivityisnotyetdetected(duetoearlystageofpregnancy).LMP:02/13/2002EDD:11/20/2002GW:8.0weeks.Patienthasbeen
2、tryingtoconceivefor6months.Menses:Onset:12yearsold.Interval:24-26days.Duration:4・6days・Flow:moderate・Complications:PMS-mild.LastPapsmeartakenon11/2/2001.Contraception:Patientiscurrentlyusingnone.Allergies:Patientadmitsallergiestovenom-bee/waspresultingindifficultybreathing,severer
3、ash,petdanderresultinginnasalstuffiness・MedicationHistory:None.PastMedicalHistory:Pastmedicalhistoryisunremarkable・PastSurgicalHistory:Patientadmitspastsurgicalhistoryoftonsillectomyin1980.SocialHistory:PatientadmitsalcoholuseDrinkingisdescribedassocial,Patientdeniesillegaldruguse
4、,PatientdeniesSTDhistory,Patientdeniestobaccouse.FamilyHistory:Patientadmitsafamilyhistoryofcancerofbreastassociatedwithmother.ReviewofSystems:Neurological:(+)unremarkable,Respiratory:(+)difficultysleeping,(-)breathingdifficulties,respiratorysymptoms,Psychiatric:(+)anxiousfeelings
5、,Cardiovascular:(-)cardiovascularproblemsorchestsymptoms,Genitourinary:(-)decreasedlibido,(-)vaginaldryness,(-)vaginalbleeding.Dietishighinemptycalories,highinfatsandlowinfiber.PhysicalExam:BPStanding:126/84Resp:22HR:78Temp:99.1Height:5ft.6in.Weight:132lbs.Pre-GravidWeightis125lbs
6、.Patientisa32yearoldfemalewhoappearspleasant,innoapparentdistress,hergivenage,welldeveloped,wellnourishedandwithgoodattentiontohygieneandbodyhabitus・Orientedtoperson,placeandtime・Moodandaffectnormalandappropriatetosituation.HEENT:Head&Face:ExaminationofheadandfaceisunremarkableSki
7、n:Noskinrash,subcutaneousnodules,lesionsorulcersobserved.Noedemaobserved・Cardiovascular:Heartauscultationrevealsnomurmurs,gallop,rubsorclicks・Respiratory:LungsCTA.Breast:Chest(Breasts):BreastinspectionandpalpationshowsnoabnormalfindingsAbdomen:Abdomensoft,nontender,bowelsoundspres
8、entx4withoutpalpablemasses・Genito
