shared via CourseHero com This study resource was 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 Women s Health 5353 SOAP Note 1G P McClintock Obstetrics and Gynecology 1100 E Lake Street Suite 260 Tyler Texas 75701CC Here for my yearly and to discuss long term birth control HPI G P is a 39 year old Hispanic female that presents to the clinic today for her yearly well womanexam 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 HxMaternal GrandmotherBreast CancerMed hxMigrain Headaches StableSurg hxTonsillectomy 2000 Social hxG 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 She is a CPA and works 40 50 hours a week Denies SmokingDenies Alcohol use shared via CourseHero com This study resource was 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 useMedsOrtho Cyclen ethinyl estradiol and norgestimate one tablet PO daily Excedrin MigrainePRN migraine Estimates 2 times week AllergiesNo Known Drug AllergiesVaccinationsTDAP 2008Flu Vaccine October 2019OB 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 forfever chills weight loss SKIN Denies rash Denies itching Denies changes in moles NECK denies swelling masses lumps or known goiterGENITALS Denies any discharge odor dysmenorrhea 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 shared via CourseHero com This study resource was 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 andhematuria PE Vitals 120 78 Pulse 78 Resp 16 Temp 98 6 F BMI 27Constitutional She is alert and oriented to person place and time She appears well developed 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 Z01419 Encounter for gynecological examination general routine Tests Pap and High Risk HPV collected todayUPTGC testHIV screening shared via CourseHero com This study resource was 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 RPRHepatitis PanelResults UPT negativeAll others waiting resultsMeds given Ortho Cyclen ethinyl estradiol and norgestimate one tablet PO daily 1 pack 12 refillsFollow up Return to clinic in 1 year or PRNEducation 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 forward with that plan