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Internal Medicine 14: 18-year-old female for pre-college physicalYanisleibis Molina GonzalezNSG6430 Practicum II: Family Health - women healthSouth university onlineOctober 3rd2020
Summary of the case study•The case study introduces us to Ms. Pham who is 18 years old and a college student.•Ms. Pham has received a full physical exam despite having no abnormal findings when she was leaving for college.•Three months after the exam show visits the office complaining about having troubles while urinating.
HPI•Some of the complains raised by Ms. Pham includes: •Bladder pain, Frequent urination, hematuria and burning effect while urinating. •A few months ago Ms. Pham claims to be sexually active with her boyfriend. •Ms. Pham says that during intercourse they always use condom.•Recently she has white discharge from her vagina.•Her last menstrual period was one week ago which was normal.•Ms. Pham denies having chills, vomiting and fever.
Medical History•Ms. Pham is not under any medication and looks relatively healthy.•Her vaccines are up to date.
Family History •The family history of Ms. Pham is not given in the case study.
Social History•Ms. Pham has friends whom they drink alcohol together once in a while.•Ms. Pham reports that she once smoked marijuana but does not smoke cigarettes. •Ms. Pham is sexually active and has a boyfriend for the first time in her life.•Interacts with other students in college.
ROS•HEENT: Normocephalic, PERRLA, good dentition, no thyroid nodules or lymphadenopathy•Skin: Intact; no lesions, rashes, or open areas•Neurological: Alert and oriented x4, appropriate at baseline, no gross sensory abnormalities•Lungs: Clear to auscultation in all lung fields.