SOAP NOTE Revise and Check for Plagiarism. SOAP NOTE Name: “Mrs. Payne” Date: 08/19/2020 Time: 1100 Family Medicine case 01 Age: 45 yo

SOAP NOTE Revise and Check for Plagiarism. SOAP NOTE

Name: “Mrs. Payne”

Date: 08/19/2020

Time: 1100

Family Medicine case 01

Age: 45 yo

Click here to Order a Custom answer to this Question from our writers. It’s fast and plagiarism-free.

Revise and Check for Plagiarism.

SOAP NOTE

Name:  “Mrs. Payne”

Date: 08/19/2020

Time: 1100

 Family Medicine case 01

Age: 45 yo

Sex: Female

SUBJECTIVE

CC: 

“Health maintenance exam”

 

HPI: 

45 yo fm G3P3 states she ultimately feels “fine” but hasn’t had a physical exam including Pap test and mammogram. Patient states menses began at age 13-14 with a regular cycle thought recently with a increased length and decreased flow. Patient also states occasional “hot flash”.

 

Medications:
Tylenol or Ibuprofen PRN for pain or headache. Multivitamin.

 

PMH

Allergies: None.

 

Medication Intolerances: None.

 

Chronic Illnesses/Major traumas – None.

 

Hospitalizations/Surgeries – Tubal Ligation.

  

Family History

Father with hypertension. Mother with mild arthritis. Two sisters in good health. Unsure but states one of her grandparents may have been diabetic. Maternal aunt with breast cancer requiring surgical intervention and chemotherapy.

 

Social History

Smokes a pack of cigarettes a week. Denies alcohol or recreational drug use. Recent decline in physical activity.

 

ROS

General

Admits to unintentional weight gain.

 

Cardiovascular

Denies chest pain or palpitations.

 

Skin

Denies bruising or rashes. Denies noted lesions.

 

Respiratory

Denies cough or wheezing. Denies shortness of breath.

 

Eyes

Denies corrective lenses or visual changes.

 

Gastrointestinal

Denies N/V/D, ABD pain, or hemorrhoids.

 

Ears

Denies otalgia or hearing loss. Denies tinnitus.

 

Genitourinary/Gynecological

Has not had a previous mammogram. Last pap smear was 5 years ago.

 

Nose/Mouth/Throat

Denies epistaxis or sinusitis.

 

Musculoskeletal

Denies joint swelling or significant back pain. Denies diagnosis of Osteoporosis.

Breast

Denies breast lumps, discharge, or pain.

Neurological

Denies history of syncope or seizures.

Heme/Lymph/Endo

Denies easy bruising, swollen glands, or intolerance of heat or cold. Admits to occasional hot flashes.

Psychiatric

Denies suicidal ideation or anxiety.

OBJECTIVE

Weight 180lb      BMI 29kg/m^2

Temp 98.6

BP 128/72

Height 5’6”

Pulse 81

Resp 12

General Appearance

Healthy appearing female, mildly overweight.

Skin

No rashes or lesions.

HEENT

Unremarkable. Good dental hygiene, noted repair with several fillings and staining due to tobacco use. Normal thyroid without evidence of thyroid nodules. Midline trachea.

Cardiovascular

S1, S2 normal without murmurs or gallops. Pulses equal throughout.

Respiratory

Lungs clear to auscultation with good respiratory excursions. No noted enlarged lymph nodes in the cervical or inguinal regions when palpated.

Gastrointestinal

No hepatosplenomegaly, masses, or tenderness.

Breast

Symmetric in shape, free of masses and discharge.

Genitourinary

Non-distended bladder. External genitalia without concerns, normal hair distribution. Cervix. If freely movable and non-tender. Normal uterus size and position. Ovaries are not palpable. No masses or lesions noted on exam.

Musculoskeletal

Normal ROM throughout. Appropriate muscle development.

Neurological

Cranial nerves intact throughout. Normal sensation, reflexes, and strength. Normal gait.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Fasting glucose – 86 mg/dl


Lipids

– Total cholesterol 183 mg/dl, HDL 52 mg/dl, LDL 121 mg/dl, Triglycerides 137 mg/dl


Pap smear results –

Satisfactory; with evidence of ASC-US; HPV negative on co-testing

 

Special Tests

 

 Diagnosis

 Differential Diagnoses

· 1- Polyp of corpus uteri (N84.0)

· 2- Osteoporosis (M81.0)

· 3- Obesity (E66.9)

Diagnosis

· Permenopasual disorder (N95.9)

Plan/Therapeutics

· Plan: 

· Follow up in three weeks to assess smoking cessation and weight management with reduced portion size and decreased “sweets”.

· Repeat co-testing in three-years.

 Evaluation of patient encounter

Place your order now for a similar assignment and have exceptional work written by one of our experts, guaranteeing you an A result.

Need an Essay Written?

This sample is available to anyone. If you want a unique paper order it from one of our professional writers.

Get help with your academic paper right away

Quality & Timely Delivery

Free Editing & Plagiarism Check

Security, Privacy & Confidentiality