SUBJECTIVE DATA:
Chief Complaint (CC): “Too many stretch marks on my stomach since being
pregnant”
History of Present Illness (HPI):
28-year-old African American woman Jessa King, JK, who is pregnant at 30 weeks
presents to the clinic complaining of feeling more anxious than usual. Although certain
parts of her belly are not painful, JK reports that but the parts might be "itchy and the
lines continue to darken." LMP: 11/26/2020, according to JK, Primigravida. Gravida 1,
Para 0. Due to her inability to wear a bikini, she asserts that she would prefer anything
to lessen the number of stretch marks. The pain reported is 0/10. JK does not
experience any fever. She tried using cocoa butter which she got over the counter but it
deemed ineffective JK therefore believes that these stretchmarks are associated with
her weight gain.
Medications:
Amlodipine: daily dose of 10 mg for HTN; Rx for pregnancy: one tablet per day;
Albuterol 90mcg: 2 puffs every six hours, PRN SOB for asthma; Uses PRN, Tylenol
325mg 2 tablets (650mg) up to three times a day for back discomfort; for seasonal
allergies, she uses 2 sprays of Nasonex daily in each nostril; Cortisone OTC: Applies 6-
8 times a day for itching; JK denies using any herbal or other dietary supplements.
Allergies:
No know food or latex allergies; Metronidazole -Systemic Uticaria; Dust -Sneezing,
itching, watery eyes; Mold -Sneezing, itching, watery eyes; Pollen -Sneezing, itching,
watery eyes
Past Medical History (PMH):
HTN- Controlled-(Dx: Age 24); Asthma-Controlled-(Dx: Age 4); Allergic Rhinitis-Stable-
(Dx: Age 7); History of Bacterial Vaginosis-Resolved; History of Chlamydia-Resolved;
History of Anxiety- Controlled without medication (Dx: Age 26)
Past Surgical History (PSH):
Umbilical hernia repair, 2005.
Sexual/Reproductive History:
JK identifies herself as bisexual and she has had intercourse with both men and
women. However, it’s been 2 years since her previous contact with a woman.
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