Women’s Health Case Study

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SOAP NOTE

Name:

Date:

Time:

Age:

Sex:

SUBJECTIVE

CC:

Reason given by the patient for seeking medical care “in quotes”

HPI:

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Medications: (list with reason for med )

PMH (include - immunization status including Gardisil, GTPLA) Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries (include delivery of pregnancies here)

“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

Family History

Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:

lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status ADD VAPING

ROS (if you are seeing a patient for an

Episodic OV –

you may alter the ROS accordingly

)

General

Weight change, fatigue, fever, chills, night sweats, energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

Eyes

Corrective lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal pain, N/V/D, …