Episodic Visit: Adolescent Focused Notes
Walden university
NURS 6541- Primary Care of Adolescents and Children
Patient Information:
Initials: T. F. Age: 17 y/o Sex: female Race: Caucasian
Date of service-September 7, 2021.
Subjective.
CC: “I have sores on my genital region”
HPI: T.F is a 17-year-old female Caucasian who presented with a complaint of sores in her
genital region. She stated that she noticed the sores three days ago, and she stated that, she had
never had sores like that before. Patient described the sore as painful, achy, itchy, and sometimes
there is a burning sensation while urinating. Patient denies drainage. The sores didn’t change the
way they look since they first appeared. No treatment was done since they were first noticed. She
states that she is sexually active, and has newly met a partner. She also states that she had had an
unprotected sexual encounter on 08/29/21. She is on contraception with Depo Provera injection,
and her last injection was on August 17, 2021. She denies fever, chills, but has a slight weight
loss of 2lb from the last visit.
Current Medications: Depo Provera 150mg/ML, IM suspension, IM injection Q12 weeks
, Allergies: No known allergies to medications, animals, environmental
PM/SHx: Childhood asthma. Not currently on any medication.
Immunization Hx:
-Hep B: Completed (ages 2 months, 4 months, and 18 months). DTap: Completed (ages 2
months,4 months, 6 months, 15 months, 6 years, and 12 years). Hib: Completed (taken at ages 2
months, 4 month, 6 months, and 15 months). IPV: Completed (2 months, 4 months, and 18
months, 6 years). PCV13: completed (ages 2 months, 4 months, 6 months, and 15 months)
Walden university
NURS 6541- Primary Care of Adolescents and Children
Patient Information:
Initials: T. F. Age: 17 y/o Sex: female Race: Caucasian
Date of service-September 7, 2021.
Subjective.
CC: “I have sores on my genital region”
HPI: T.F is a 17-year-old female Caucasian who presented with a complaint of sores in her
genital region. She stated that she noticed the sores three days ago, and she stated that, she had
never had sores like that before. Patient described the sore as painful, achy, itchy, and sometimes
there is a burning sensation while urinating. Patient denies drainage. The sores didn’t change the
way they look since they first appeared. No treatment was done since they were first noticed. She
states that she is sexually active, and has newly met a partner. She also states that she had had an
unprotected sexual encounter on 08/29/21. She is on contraception with Depo Provera injection,
and her last injection was on August 17, 2021. She denies fever, chills, but has a slight weight
loss of 2lb from the last visit.
Current Medications: Depo Provera 150mg/ML, IM suspension, IM injection Q12 weeks
, Allergies: No known allergies to medications, animals, environmental
PM/SHx: Childhood asthma. Not currently on any medication.
Immunization Hx:
-Hep B: Completed (ages 2 months, 4 months, and 18 months). DTap: Completed (ages 2
months,4 months, 6 months, 15 months, 6 years, and 12 years). Hib: Completed (taken at ages 2
months, 4 month, 6 months, and 15 months). IPV: Completed (2 months, 4 months, and 18
months, 6 years). PCV13: completed (ages 2 months, 4 months, 6 months, and 15 months)
