Charting Exercise: case 10



Charting Exercise: case 10

Client name: Suzy Q DOB: XX-XX-1991

Clinic ID: 10

Date Seen: XX-XX-2007

Purpose of visit: c/o severe pain with period, worse than usual.

History Present Illness:

Location: Timing:

Quality: Context:

Severity: Modifying Factors slight improvement with Midol

Duration: Assoc. signs & Symptoms:

Review of History (Past, Family and Social):

Vital Signs: P:88 R:16 T:99.0 BP:110/72 HT: 63” WT: 124#

|Review of Systems |Notes |Exam |WNL |NOTES |

|Constitutional: | |Constitution | N |Ill appearing, grimacing |

|Eyes | |Heart | | |

|ENMT | |Lungs | | |

|Cardiovascular | |Eyes | | |

|Respiratory | |ENT | | |

|Gastrointestinal | |Mouth | | |

|Genitourinary |Has cramps w/ ea |Neck | | |

| |period | | | |

|Musculoskeletal | |Abdomen | Y |Non-Tender to palpation |

|Skin | |Chest | | |

|Neurological | |Skin | | |

|Psychiatric | |Back | N |Lower back tense to palpation |

|Endocrine | |Extremities | | |

|Hematological/Lymphatic | |Neuro/reflex | | |

|Allergy/Immunological | |Genitourinary | N |Pelvic area tender to palpation |

Assessment: dysmenorrhea

Plan: Ibuprophen OTC 200 mg i to ii tabs q 8 hrs, apply heating pad to abdomen. RTC if not improved tomorrow

Examiner Signature: N. Nurse, FNP

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