Comprehensive History And Physical Examination

849 WordsJul 18, 20164 Pages
Comprehensive History and Physical Examination Patient Name: MM Sex: Female DOB: July 7, 1992 Date: 7/17/16 Chief Complaint: “I want to be screen for an STI” History of Present Illness: MM is a 24-year-old Caucasian female that presents at the clinic. She is a relatively healthy female who wants to be screened for an STI after becoming sexual active again. Her last menstrual was last week and is “not concerned that she is pregnant.” Additionally, the patient has no intentions of becoming pregnant. However, MM, is not currently taking any medications to prevent pregnancy. MM states that she is able to achieve orgasm. The patient claims that she participates in oral and vaginal sex. During intercourse the patient says that a condom is always used. The patient states that she has had a total of 3 lifetime partners. All of whom were heterosexual males. Currently, the patient only has one partner and has never had a STI. Patient states last pap smear was 3 years ago. Past Medical History: 1. Appendix removed at 15 2. Dislocated shoulder playing volleyball, denies surgery 3. Spent one night in Hospital after severe concussion Past Surgical History: 1. Appendix removed at 15 Medications: 1. Patient takes multivitamins 2. Denies any medications Immunizations: 3. Patient states she is up to date on all immunizations and does receive yearly flu shot Allergies: Drug: None known Environmental: Seasonal allergies which patient states are under control Food: Dairy
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