Family Health - Week 2 SOAP NOTE - Revision

Name:  DL

Date: 9/30/2022

Time: 10:00 am

Age: 28 years

Sex: Female

SUBJECTIVE

CC: 

“I have my period for 22 days; I have pelvic pain and also noted some dark vaginal bleeding since yesterday.”

HPI: The patient states that she noted the darker bleeding yesterday. She has been having pelvic pain although she did not mention if it was severe, but some time she felt nauseous. She also states that she has been having her periods for the last 22 days although she noted the darker bleeding yesterday. She has been having pelvic pain. The patient took ibuprofen 400 mg to alleviate the pain.

Medications: Ibuprofen 400 mg PO Q6H as needed for pain

PMH:

Allergies:  NKA

Medication Intolerances: Patient reports no known medical intolerance.

Immunizations: Immunization up to date

Chronic Illnesses/Major traumas: None reported

Hospitalizations/Surgeries no mention of any surgery or hospitalization.

Family History:

Both patents are alive. Only child. For the first-degree relatives there is no mention of malignancy.  

Social History: Patient was born in Cuba, came to US with her current boyfriend 2 years ago. Patient lives with her boyfriend. The patient denies any smoking, drinking, or any use of recreational drugs. The patient explains that she has been maintaining a regular diet and goes to the gym 2 or 3 times per week and usually sleep 7-8 hours daily. There is also no drug or tabaco use history in his family.

ROS

General- the patient states that her periods are 22 days, she has pelvic pain and that yesterday she noticed dark vaginal bleeding. From yesterday.

Cardiovascular

She denies any chest pains, palpitations nor pressure.

Skin

 No changes on her skin

Respiratory

 No coughing nor shortness of breath.

Eyes- she has no double vision, loss of vision, or blurred vision.

Gastrointestinal

 The patient denies any nausea, vomiting or diarrhea, constipation but she states that she has pelvic pain.

Ears

 No ear pain nor loss of hearing.

Genitourinary/Gynecological

 She denies pain when urinating, she has vaginal discharge where she has noticed dark vaginal bleeding.

Nose/Mouth/Throat

No mouth pain, mouth discharge, throat pain nor having issues when swallowing.

Musculoskeletal

No bones, muscles, and joints pain and she deny constraint to a range motion, swelling of joints.

Breast

Denies any discomfort or lumps.

Neurological

She denies dizziness, headache, ataxia, or syncope.

Heme/Lymph/Endo

Denies any swollen gland, vaginal bleeding, and no sweats.

Psychiatric

No depression, insomnia, mood swings, or anxiety.

OBJECTIVE

Weight: 167.0lbs

Temp: 97.5F

BP: 115/77mgHg

Height: 5.8”

Pulse: 77 beats per minute

Resp: 17/min

General Appearance

The patient appears to be normal; she has no acute distress, and she is well-nourished and well developed. She is oriented, alert, and cooperative with the examination.

Skin The skin of the patient is normal without cyanosis, clubbing or bruises. No symptom of dehydration is seen from, warm to touch, and the turgor of her skin is normal.

HEENT

Normocephalic, PERRLA, Pharynx is noted not to be having any difficulties in swallowing, neck, thyroid non palpable, no carotid bruits, TM intact bilaterally.

Cardiovascular

Patient has no murmurs, gallops, or clicks. The S1 and S2 are present.

Respiratory

She has a normal respiratory effort, and her lungs are free to auscultation bilaterally, and she has no rales or wheezing in her lungs.

Gastrointestinal

Abdomen is flat with active bowel sounds in all four quadrants. It is soft and non-tender, no masses or hepatosplenomegaly. No CVA tenderness.

Breast Normal, no lumps or discomfort.

Genitourinary:

She does not experience pain when urinating.

Musculoskeletal

No noted joint deformities. Positive ROM in all extremities.

Neurological

Cranial nerves intact. Stable gait.

Psychiatric- she is alert, oriented x3 as well as cooperative with the examination.

Lab Tests (list the results if you have them)

Special Tests (done or ordered during the OV)

Pap Smear

Pelvic Exam

STD & HIV Screening/Counseling

 Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used

Plan/Therapeutics (explain fully)

Evaluation of patient encounter:

I saw this patient with my preceptor. I participated in the differential diagnosis selection.

Weakness: I need to participate more and feel more comfortable on my own.

Strengths: I have improved my physical exam skill.

Reflection: I need to study more to feel more comfortable while giving a diagnosis.