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SOAP NOTE
Name:
“Mrs. Payne” |
Date: 08/19/2020 |
Time: 1100 |
Family Medicine case 01 |
Age: 45 yo |
Sex: Female |
SUBJECTIVE |
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CC: “Health maintenance exam”
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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”.
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Medications:
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PMH Allergies: None.
Medication Intolerances: None.
Chronic Illnesses/Major traumas – None.
Hospitalizations/Surgeries – Tubal Ligation.
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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.
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Social History Smokes a pack of cigarettes a week. Denies alcohol or recreational drug use. Recent decline in physical activity.
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ROS |
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General Admits to unintentional weight gain.
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Cardiovascular Denies chest pain or palpitations.
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Skin Denies bruising or rashes. Denies noted lesions.
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Respiratory Denies cough or wheezing. Denies shortness of breath.
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Eyes Denies corrective lenses or visual changes.
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Gastrointestinal Denies N/V/D, ABD pain, or hemorrhoids.
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Ears Denies otalgia or hearing loss. Denies tinnitus.
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Genitourinary/Gynecological Has not had a previous mammogram. Last pap smear was 5 years ago.
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Nose/Mouth/Throat Denies epistaxis or sinusitis.
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Musculoskeletal Denies joint swelling or significant back pain. Denies diagnosis of Osteoporosis. |
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Breast Denies breast lumps, discharge, or pain. |
Neurological Denies history of syncope or seizures. |
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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. |
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OBJECTIVE |
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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. |
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Skin No rashes or lesions. |
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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. |
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Cardiovascular
S1, S2 normal without murmurs or gallops. Pulses equal throughout. |
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Respiratory
Lungs clear to auscultation with good respiratory excursions. No noted enlarged lymph nodes in the cervical or inguinal regions when palpated. |
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Gastrointestinal
No hepatosplenomegaly, masses, or tenderness. |
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Breast
Symmetric in shape, free of masses and discharge. |
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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. |
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Musculoskeletal
Normal ROM throughout. Appropriate muscle development. |
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Neurological Cranial nerves intact throughout. Normal sensation, reflexes, and strength. Normal gait. |
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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. |
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Lab Tests Fasting glucose – 86 mg/dl
Lipids
Pap smear results –
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Special Tests
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Diagnosis |
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Differential Diagnoses · 1- Polyp of corpus uteri (N84.0) · 2- Osteoporosis (M81.0) · 3- Obesity (E66.9) Diagnosis · Permenopasual disorder (N95.9) |
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Plan/Therapeutics |
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· 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. |
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Evaluation of patient encounter |