Chief complaint-66-year-old female presents to the office with a 3 week history of spotting on 3 separate days in the last month. Only occurred one month. PMH-Epilepsy, Hypothyroidism, Oste
SOAP note along with ROS and Physical exam for a patient that presents with the following:
You will need to place the information in the appropriate sections and your own ROS, physical exam and differentials as per the template.
Chief complaint-66-year-old female presents to the office with a 3 week history of spotting on 3 separate days in the last month. Only occurred one month.
PMH-Epilepsy, Hypothyroidism, Osteoarthritis, Hyperlipidemia, Rheumatoid Arthritis, Osteopenia, Dementia (Alzheimer’s type), Severe intellectual disability, Depression, HSV-1
Social History-Non-smoker, lives in single family home with 2 other ladies and a 24 hour caregiver, no history of sexual activity, low fat diet, minimal exercise
FMH-not known
Menstrual:: has had 3 episodes of spotting on 3 separate days in the last month. States that it occurs only once a month. Patient reports no fatigue, no fever, no significant weight gain, and no significant weight loss. She reports no dyspnea / shortness of breath, no cough, no sputum production, no hemoptysis, and no wheezing. She reports no chest pain, no palpitations, and no orthopnea. She reports no hematuria, no abnormal bleeding, no flank pain, no trouble urinating, no incontinence, no rash, no lesion, no discharge, no vaginal odor, and no vaginal itching.
Allergy-Guaifenesin, Entex LA
Medications-
Abreva 10% topical cream, Acetaminophen, Budesonide, Carbamazepine, Certavite, Cetirizine, Vitamin D3, Citrucel, Delsym, Benadryl, Donepezil, Fluoxetine, Ibuprofen, Lorazepam, Memantine, Phenytoin, Pravastatin, Resperidone, Valacyclovir
Bone Density-2021
Mammogram-2022
Vital Signs:
Ht. 5’3, Wt. 219, B/P 120/78, T-97.1, P-68, O2-96% RA BMI-38.8
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