Name: Lara Taylor Pt. Encounter Number: 3
Date: April 8th, 2025 Age: 35 y. o Sex: Female
SUBJECTIVE
CC:
“I’m here for my prenatal visit”
HPI:
“I’m about 20 weeks pregnant” has no other complaints except for occasional lower back pain.
This pain is worse when she stand and as relief when she sits and rests. This is her third
pregnancy. She had an elective abortion and a miscarriage in the past.
Medications: Taking OTC prenatal vitamins. Took Lexapro in the past for depression
Allergies: Latex – Rash
Medication Intolerances: None
Past Medical History:
Episodes of depression in the past, twice
Chronic Illnesses/Major traumas – none
Hospitalizations/Surgeries
First pregnancy at 15 weeks, for elective abortion
Second pregnancy miscarriage , had a dilation and curettage
Family History
Father – passed at age 60 after, a heart attack
Mother – alive, diabetic for 10 years now
Brother – alive, no health issues
Social History
College educated, got a certification in education, she is a substitute teacher. Married recently.,
a month ago. She stated she does not smoke, or drink alcohol and has never used drugs or
other substances.
ROS Student to ask each of these questions to the patient: “Have you had any…..”
General Cardiovascular
Positive for Weight change,, patient stated she Negative for Chest pain, palpitations, PND,
weighed 155 lbs, now weighing 167 lbs since orthopnea, and edema
pregnancy.
Negative for fatigue, fever, chills, night
sweats, and energy level
Skin Respiratory
Negative for Delayed healing, rashes, bruising, Negative for Cough, wheezing, hemoptysis,
bleeding or skin discolorations, and any dyspnea, pneumonia hx, and TB
changes in lesions or moles
Eyes Gastrointestinal
Negative for Corrective lenses, blurring, and Negative for Abdominal pain, N/V/D,
visual changes of any kind constipation, hepatitis, hemorrhoids, eating
disorders, ulcers, and black, tarry stools
Date: April 8th, 2025 Age: 35 y. o Sex: Female
SUBJECTIVE
CC:
“I’m here for my prenatal visit”
HPI:
“I’m about 20 weeks pregnant” has no other complaints except for occasional lower back pain.
This pain is worse when she stand and as relief when she sits and rests. This is her third
pregnancy. She had an elective abortion and a miscarriage in the past.
Medications: Taking OTC prenatal vitamins. Took Lexapro in the past for depression
Allergies: Latex – Rash
Medication Intolerances: None
Past Medical History:
Episodes of depression in the past, twice
Chronic Illnesses/Major traumas – none
Hospitalizations/Surgeries
First pregnancy at 15 weeks, for elective abortion
Second pregnancy miscarriage , had a dilation and curettage
Family History
Father – passed at age 60 after, a heart attack
Mother – alive, diabetic for 10 years now
Brother – alive, no health issues
Social History
College educated, got a certification in education, she is a substitute teacher. Married recently.,
a month ago. She stated she does not smoke, or drink alcohol and has never used drugs or
other substances.
ROS Student to ask each of these questions to the patient: “Have you had any…..”
General Cardiovascular
Positive for Weight change,, patient stated she Negative for Chest pain, palpitations, PND,
weighed 155 lbs, now weighing 167 lbs since orthopnea, and edema
pregnancy.
Negative for fatigue, fever, chills, night
sweats, and energy level
Skin Respiratory
Negative for Delayed healing, rashes, bruising, Negative for Cough, wheezing, hemoptysis,
bleeding or skin discolorations, and any dyspnea, pneumonia hx, and TB
changes in lesions or moles
Eyes Gastrointestinal
Negative for Corrective lenses, blurring, and Negative for Abdominal pain, N/V/D,
visual changes of any kind constipation, hepatitis, hemorrhoids, eating
disorders, ulcers, and black, tarry stools
