Womens Health Soap Note X4 (Due 24 hours)
SOAP NOTE
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Patient Initials: |
Pt. Encounter Number: |
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Date: |
Age: |
Sex: |
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Allergies: Advanced Directives:
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SUBJECTIVE |
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CC:
In quotation marks indicate the patient's complaint
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Follow the example. You must address the fundamental aspects of the patient, such as age, complaint, symptoms, time with symptoms, health problems ...
HPI: Mr. FG is 71 years old male patient who presents today for the annual wellness visit. He was well oriented in time, place and person. He did not report any kind of illness except occasional lower back pain, after all he is suffering from a number of chronic conditions but he is taking proper guidelines and working on them. He denied any type of mentally or behavioral illness. He denied fever and chills, nausea and vomiting. The patient is living with his family happily.
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Current Medications: Indicate if the patient is consuming any medication.
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Follow the lead according to the disease
PMH
Medication Intolerances: None
Chronic Illnesses/Major traumas: Cardiac cath, “Operated 2007”.
Screening Hx/Immunizations Hx: No history of immunization. Rheumatoid factor. Urinary analysis. Angiography. Chest X-rays. Dexa scan. Ekg, Dental exam, eye exam, colonoscopy, spirometery.
Hospitalizations/Surgeries: Hernia repair 1975, RT knee replacement 2004, fistulectomy 1975, partial prostatectomy 2014.
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Follow the lead according to the disease
Family History : Father died of hemorrhage, Ulcer, gastric Mother died of kidney disease.
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Follow the lead according to the disease
Social History: Ex-smoker, drink on and off.
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Follow the lead according to the disease In this case, the symptoms should focus on "Genitourinary / Gynecological" and other related systems- symptoms that the patient refers to their disease.
You must use different wording to complete "ROS"
ROS
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General Alert no change in physical appearance, strength, weight and no fever and chills |
Cardiovascular No chest pain, no palpitations, no orthopnea. Regular rhythm, pulse rate normal |
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Skin Normal, in color, no lesion, no rash. |
Respiratory No cough, sputum, chest normal in shape, no abnormal breathing sound. |
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Eyes Normal vision, denied any pain and blurred vision |
Gastrointestinal Normal appetite, normal bowel habit. |
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Ears Denied from vertigo, change in hearing, tinnitus. |
Genitourinary/Gynecological
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Nose/Mouth/Throat Nose: No obstruction. No discharge, denied bleeding, no epistaxis. Mouth: normal mucosal lining. Throat: Normal in shape, no abnormal mas found.
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Musculoskeletal Occasional lower back pain, denied any joint or muscle pain. |
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Breast Normal |
Neurological Intact sensory and motor system, normal DTR |
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Heme/Lymph/Endo Normal, no swelled lymph nodes. Normal thyroid gland.
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Psychiatric Normal, denied any type of psychiatric issue. |
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OBJECTIVE Follow the lead according to the patient
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Weight 174 lb. BMI 30.82 |
Temp 97.90 F |
BP 139/78 mmhg |
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Height 63” |
Pulse 64 bpm |
Resp 18bpm |
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PHYSICAL EXAMINATION Follow the lead according to the disease
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General Appearance Alert and oriented x 3. The patient is well-groomed, who responds to questions quickly and appropriately. She is dress appropriate to the occasion and has a normal posture. |
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Skin Normal in color and texture |
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HEENT Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. No aphasia receptive or expressive. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movement intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions. Lids non-remarkable and appropriate for race. Neck negative for masses, no noticeable or palpable swelling, redness or rash around throat or on face. No thyromegaly. No JVD distention. Teeth are in good repair |
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Cardiovascular No splitting of the heart sounds heard. No murmur. No S3 or S4. No friction rubs. Patient denies chest pain. S1, S2 with regular rate and rhythm. No extra heart sounds. No SOB, no JVD, no carotid bruits. |
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Respiratory Symmetric chest walls. Respirations regular and easy. Clear to auscultation, no use of accessory muscles, no crackles or wheezes. |
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Gastrointestinal Abdomen flat, soft, no painful to palpation. BS active in all 4 quadrants. No hepatosplenomegaly |
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Breast No mass noted, no fulness sensation, pain, or discharge reported. No prior history of breast biopsy, lesions, pain, or discharge. |
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Genitourinary
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Musculoskeletal No history of falls reported, denies weakness, muscular pain, swollen ,or any other inflammatory symptoms in the joints. Denies joint pain, limited ROM, difficulty walking, or trouble reaching above head. |
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Neurological Denies history of seizure disorder, stroke, head injury, tremors, or involuntary movements, vertigo, spinal cord injury, meningitis, blackouts, paralysis, fainting, dizziness, numbness, or loss of sensation. The memory is good.
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Psychiatric Patient states no changes in mood, denies anxiety, depression, or insomnia. Denies low self-esteem, feeling sad, social isolation, or attention deficit, no change in thought patterns. |
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Lab Tests Follow the lead according to the disease MRI of back, X-ray of spine, CBC, Urinary analysis, Lipid profile. |