Student Name: wisline Dorvil Course: NSG6440
Patient Name: R.M. Date:09/07/2025 Time: 10:00 AM
Ethnicity: African Age: 35-Y/0 Sex: F
SUBJECTIVE
CC:
“I have been having pain in my lower abdomen for the past four days.”
HPI:
R.M. is a 35-Y/O with progressively worsening lower abdominal pain. The pain began four days ago as a dull
ache localized in the suprapubic region but has since intensified to a constant cramping discomfort, rated 7/
on the pain scale. Pain is exacerbated by movement and partially relieved by rest. She denies radiation of pa
but reports associated bloating and mild nausea without vomiting. No diarrhea, melena, or hematochezia. S
describes increased urinary frequency with mild burning sensation but denies hematuria. Her period are
regular and the last period was three weeks ago. R.M. is sexually active with one partner, not currently on
contraceptives. No history of abnormal vaginal discharge or recent new sexual partners.
Medications:
Occasional use of ibuprofen 400 mg for dysmenorrhea. No other prescribed medications.
Previous Medical History: Dysmenorrhea since adolescence.
Allergies: Denies drug or food allergies.
Medication Intolerances: None.
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: Appendectomy at age 14. No complications.
FAMILY HISTORY
, M: Alive, 60 years old, diagnosed with hypertension
at 50, on medication.
MGM: Deceased at 72, history of stroke and long-standing
hypertension.
MGF: Alive, 80, history of osteoarthritis, otherwise healthy.
F: Alive, 62 years, diagnosed with type 2 diabetes at
55, well controlled with oral hypoglycemics.
PGM: Deceased at 70, had colon cancer diagnosed at age 68.
PGF: Alive, 85 years, history of ischemic heart disease.
Social History: R.M. is lives with her husband and two children. She works full-time as an accountant in a
private firm and reports moderate occupational stress, particularly during monthly reporting periods. She
drinks alcohol occasionally, averaging one to two glasses of wine on weekends. Her diet consists of mixed
meals but includes frequent fast food when busy at work. She exercises irregularly, mostly walking with her
children a few times a week, but does not have a structured exercise routine. She is not currently on
contraceptives. She identifies as Christian and attends church regularly, which she describes as a source of
emotional and spiritual support.
REVIEW OF SYSTEMS
General: Reports fatigue related to abdominal Cardiovascular: No chest pain, or peripheral edema
discomfort.
Skin: No rashes, bruises, lesions, or discoloration Respiratory: No cough, wheezing, or hemoptysis.
observed.
Eyes: No discharge, swelling or pain noted. Gastrointestinal: Reports suprapubic abdominal pai
bloating, and mild nausea. Denies constipation,
hematochezia, or melena. No changes in appetite.
Ears: Clear ear canals, no discharge. Genitourinary/Gynecological: Reports urinary
frequency and mild burning on urination. Denies
hematuria, flank pain, or incontinence.
Nose/Mouth/Throat: Nasal passages are clear Musculoskeletal: No joint pain, swelling, or stiffness
without obstruction, polyps, or discharge. Oral mucosa
has no lesions, ulcers, or thrush. Pharynx appears
nonerythematous with no exudate. Tonsils not
enlarged.
No hoarseness.
Breast: Breasts are symmetrical, without visible skin Neurological: Denies weakness. No speech or balanc
dimpling, retractions, or nipple discharge. problems.
Heme/Lymph/Endo: No cervical, lymphadenopathy Psychiatric: Denies depression, sleep disturbance
appreciated. No petechiae, purpura, or unexplained beyond pain-related discomfort, or history of
bruising noted. Thyroid gland is non-enlarged, without psychiatric illness.
palpable nodules or tenderness. No tremors, heat or
cold intolerance, or diaphoresis noted during exam.
10122023 Page 2 of 8
Patient Name: R.M. Date:09/07/2025 Time: 10:00 AM
Ethnicity: African Age: 35-Y/0 Sex: F
SUBJECTIVE
CC:
“I have been having pain in my lower abdomen for the past four days.”
HPI:
R.M. is a 35-Y/O with progressively worsening lower abdominal pain. The pain began four days ago as a dull
ache localized in the suprapubic region but has since intensified to a constant cramping discomfort, rated 7/
on the pain scale. Pain is exacerbated by movement and partially relieved by rest. She denies radiation of pa
but reports associated bloating and mild nausea without vomiting. No diarrhea, melena, or hematochezia. S
describes increased urinary frequency with mild burning sensation but denies hematuria. Her period are
regular and the last period was three weeks ago. R.M. is sexually active with one partner, not currently on
contraceptives. No history of abnormal vaginal discharge or recent new sexual partners.
Medications:
Occasional use of ibuprofen 400 mg for dysmenorrhea. No other prescribed medications.
Previous Medical History: Dysmenorrhea since adolescence.
Allergies: Denies drug or food allergies.
Medication Intolerances: None.
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: Appendectomy at age 14. No complications.
FAMILY HISTORY
, M: Alive, 60 years old, diagnosed with hypertension
at 50, on medication.
MGM: Deceased at 72, history of stroke and long-standing
hypertension.
MGF: Alive, 80, history of osteoarthritis, otherwise healthy.
F: Alive, 62 years, diagnosed with type 2 diabetes at
55, well controlled with oral hypoglycemics.
PGM: Deceased at 70, had colon cancer diagnosed at age 68.
PGF: Alive, 85 years, history of ischemic heart disease.
Social History: R.M. is lives with her husband and two children. She works full-time as an accountant in a
private firm and reports moderate occupational stress, particularly during monthly reporting periods. She
drinks alcohol occasionally, averaging one to two glasses of wine on weekends. Her diet consists of mixed
meals but includes frequent fast food when busy at work. She exercises irregularly, mostly walking with her
children a few times a week, but does not have a structured exercise routine. She is not currently on
contraceptives. She identifies as Christian and attends church regularly, which she describes as a source of
emotional and spiritual support.
REVIEW OF SYSTEMS
General: Reports fatigue related to abdominal Cardiovascular: No chest pain, or peripheral edema
discomfort.
Skin: No rashes, bruises, lesions, or discoloration Respiratory: No cough, wheezing, or hemoptysis.
observed.
Eyes: No discharge, swelling or pain noted. Gastrointestinal: Reports suprapubic abdominal pai
bloating, and mild nausea. Denies constipation,
hematochezia, or melena. No changes in appetite.
Ears: Clear ear canals, no discharge. Genitourinary/Gynecological: Reports urinary
frequency and mild burning on urination. Denies
hematuria, flank pain, or incontinence.
Nose/Mouth/Throat: Nasal passages are clear Musculoskeletal: No joint pain, swelling, or stiffness
without obstruction, polyps, or discharge. Oral mucosa
has no lesions, ulcers, or thrush. Pharynx appears
nonerythematous with no exudate. Tonsils not
enlarged.
No hoarseness.
Breast: Breasts are symmetrical, without visible skin Neurological: Denies weakness. No speech or balanc
dimpling, retractions, or nipple discharge. problems.
Heme/Lymph/Endo: No cervical, lymphadenopathy Psychiatric: Denies depression, sleep disturbance
appreciated. No petechiae, purpura, or unexplained beyond pain-related discomfort, or history of
bruising noted. Thyroid gland is non-enlarged, without psychiatric illness.
palpable nodules or tenderness. No tremors, heat or
cold intolerance, or diaphoresis noted during exam.
10122023 Page 2 of 8
