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Comprehensive Soap Note Essay

2039 words - 9 pages

Initials: J.K.
Age: 39
Sex: F
Race: Caucasian

Health Care Profile

Medications and Med Synthesis: Tramadol 50 mg prn

Allergies: NKDA

Reason for Contact: annual exam and pap smear

History of Present Illness: Last pap was 10 years ago and was abnormal. Patient has been having heavy but regular periods for the past year. Bleeding seems to be worsening monthly. Patient reports y days of bleeding with the first 2-3 so heavy that she is soaking through a super plus tampon and pad hourly day and night. She is fatigued all of the time but has increased fatigue the week of her cycle. She has large clots and very heavy cramping and back pain associated with cycles. She ...view middle of the document...

Stroke/PVD: maternal grandfather
j. Allergies: Cefzil and Neurontin
k. Kidney disease: denies

Review of Systems

Skin: Denies rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles.

Hair: Denies alopecia/hirsutism, texture/appearance changes.

Head and face: Denies head injury, dizziness, lightheadedness, facial/neck pain, or swollen glands. Does experience “some” lightheadedness with position changes the week of her cycle. Denies persistent headaches. Denies any visual changes or disturbances.

Eyes: Denies use of glasses or contacts. Denies pain, redness, swelling, trauma, excessive tearing/drying, discharge, double or blurred vision, spots, specks, flashing lights, blind spots, glaucoma, cataracts or other changes in visual fields/acuity.

Ears: Denies hearing loss, tinnitus, vertigo, earaches, infection, discharge or use of hearing aids.

Nose and Sinuses: Denies frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, or sinus trouble.

Mouth and Throat: Denies any recent cavities; brushes and flosses twice daily; Denies soreness, lesions, bleeding, sores, toothache, sore throat, dryness/excessive salivation, hoarseness, or use of prosthetic devices.

Neck and Nodes: Denies tenderness, pain, stiffness, masses, or swollen glands.

Breasts: Denies change in size/appearance, masses, swelling, tenderness, pain, or discharge.

Respiratory: Denies cough, wheezing, asthma, bronchitis, pneumonia, sputum production, hemoptysis, and dyspnea.

Cardiac: Denies chest pain/discomfort, palpitations, edema, orthopnea, paroxysmal nocturnal dyspnea. History of a ablation for Atrial Supraventricular Tachycardia in 2012. Denies SVT sensations since that time.

Gastrointestinal: Describes appetite as good. Denies dysphagia, odynophagia, nausea, vomiting, diarrhea, hemorrhoids, abdominal pain, excessive gas/belching, jaundice, liver, or gallbladder trouble. Complains of intermittent constipation but it is controlled with diet or Milk of Magnesia PRN.

Urinary: Denies urgency, dysuria, hematuria, hesitancy, or incontinence with sneezing, coughing, laughing or other activity. Abdominal, flank pain, suprapubic pain, and ureteral colic denied. Denies polyuria or nocturia.

Genitoreproductive: Complains of increased heavy menses, large clots, heavy cramping, and back pain associated with cycles. Cycles occur approximately every 28 days. The duration of her recent periods have been regular and usually last 6 days. G3 P (A2 L1)

Peripheral Vascular: Denies claudication, leg cramps, and varicose veins, past clots in the veins, swelling in calves, legs or feet, color or change in fingertips or toes during cold weather, or swelling with redness or tenderness.

Musculoskeletal: Denies birth trauma and family history of skeletal or genetic problems. Denies any clumsiness, limping, gait abnormalities,...

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