Women’s Health 5353 SOAP Note #1 G.P. McClintock Obstetrics and Gynecology 1100 E. Lake Street, Suite 260 Tyler, Texas 75701 CC: “Here for my yearly and to discuss long term birth control.” HPI: is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m G.P. is a 39-year-old Hispanic female that presents to the clinic today for her yearly well woman exam. She denies any gynecological concerns. She receives her routine lab work at her PCP. G.P. was last seen a year ago this month for pelvic exam and was prescribed a year of oral birth control. Family Hx Maternal Grandmother Med hx Breast Cancer Migrain/Headaches-Stable Surg hx Tonsillectomy-2000 Social hx Th G.P. lives in a single story home with her husband and 2 youngest children ages 11 and 10. She has three adult children (ages 24, 23 and 19) that live close by and 3 grandchildren. sh She is a CPA and works 40-50 hours a week. Denies Smoking Denies Alcohol use This study source was downloaded by 100000770747961 from CourseHero.com on 03-26-2021 13:56:11 GMT -05:00 https://www.coursehero.com/file/71488411/5353-Clincal-SOAP-Note-1docx/ Denies recreational drug use Meds Ortho Cyclen (ethinyl estradiol and norgestimate) one tablet PO daily Excedrin Migraine PRN migraine (Estimates 2 times/week) Allergies No Known Drug Allergies Vaccinations is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m TDAP-2008 Flu Vaccine-October 2019 OB/GYN hx G5P5, last pap contesting negative 2015, last pelvic exam Feb 2019 STI screening Feb 2019. ROS: CONSTITUTIONAL: Denies weight gain. Denies fatigue, and general weakness. Negative for fever, chills, weight loss. SKIN: Denies rash. Denies itching. Denies changes in moles. NECK: denies swelling, masses, lumps, or known goiter Th GENITALS: Denies any discharge, odor, dysmenorrhea. sh BREASTS: Denies any lumps, bumps and nipple discharge or discoloration. CHEST/THORAX/RESPIRATORY: Denies SOB. Denies coughing and sputum production. CARDIOVASCULAR/HEART: Denies edema. denies Chest pain, chest pressure or chest This study source was downloaded by 100000770747961 from CourseHero.com on 03-26-2021 13:56:11 GMT -05:00 https://www.coursehero.com/file/71488411/5353-Clincal-SOAP-Note-1docx/ discomfort. Denies Palpitations, Murmur, Rhythm/arrhythmia. GENITOURINARY: Denies incontinence. Denies Burning on urination, urgency, and hematuria. PE: Vitals 120/78 Pulse 78 Resp: 16 Temp 98.6 F BMI 27 Constitutional: She is alert and oriented to person, place, and time. She appears well-developed is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m and overweight. Neck: Normal range of motion. Neck supple. No evidence of thyromegaly. Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Pulmonary/Chest: Effort normal. Lungs clear bilaterally. Breast: Left: No chest deformity, asymmetry. Normal contours. No nodules, masses, tenderness, or axillary adenopathy. No nipple discharge. Right: No chest deformity, asymmetry. Normal contours. No nodules, masses, tenderness, or axillary adenopathy. No nipple discharge. Genital: Normally developed genitalia with no external lesions or eruptions. Vagina and cervix show no lesions, inflammation, discharge or tenderness. No cystocele. Abdominal: Soft. Bowel sounds are normal. Differentials: Tests: Th Z01419 - Encounter for gynecological examination (general) (routine) UPT sh Pap and High Risk HPV collected today GC test HIV screening This study source was downloaded by 100000770747961 from CourseHero.com on 03-26-2021 13:56:11 GMT -05:00 https://www.coursehero.com/file/71488411/5353-Clincal-SOAP-Note-1docx/ RPR Hepatitis Panel Results: UPT-negative All others: waiting results Meds given: Ortho Cyclen (ethinyl estradiol and norgestimate) one tablet PO daily #1 pack #12 refills is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m Follow up: Return to clinic in 1 year, or PRN Education: Pt educated on birth control options including IUD, tubal ligation, oral and implantation. Pt interested in possible tubal ligation. Pt instructed to call to schedule if she decides to move sh Th forward with that plan. This study source was downloaded by 100000770747961 from CourseHero.com on 03-26-2021 13:56:11 GMT -05:00 https://www.coursehero.com/file/71488411/5353-Clincal-SOAP-Note-1docx/ Powered by TCPDF (www.tcpdf.org)
