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Name: DL
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Date: 9/30/2022
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Time: 10:00 am
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Age: 28 years
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Sex: Female
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SUBJECTIVE
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CC:
“I have my period for 22 days; I have pelvic pain and also noted some dark vaginal bleeding since yesterday.”
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HPI: The patient states that she noted the darker bleeding yesterday. She has been having pelvic pain although she did not mention if it was severe, but some time she felt nauseous. She also states that she has been having her periods for the last 22 days although she noted the darker bleeding yesterday. She has been having pelvic pain. The patient took ibuprofen 400 mg to alleviate the pain.
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Medications: Ibuprofen 400 mg PO Q6H as needed for pain
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PMH:
Allergies: NKA
Medication Intolerances: Patient reports no known medical intolerance.
Immunizations: Immunization up to date
Chronic Illnesses/Major traumas: None reported
Hospitalizations/Surgeries no mention of any surgery or hospitalization.
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Family History:
Both patents are alive. Only child. For the first-degree relatives there is no mention of malignancy.
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Social History:
Patient was born in Cuba, came to US with her current boyfriend 2 years ago. Patient lives with her boyfriend. The patient denies any smoking, drinking, or any use of recreational drugs. The patient explains that she has been maintaining a regular diet and goes to the gym 2 or 3 times per week and usually sleep 7-8 hours daily. There is also no drug or tabaco use history in his family.
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ROS
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General- the patient states that her periods are 22 days, she has pelvic pain and that yesterday she noticed dark vaginal bleeding. From yesterday.
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Cardiovascular
She denies any chest pains, palpitations nor pressure.
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Skin
No changes on her skin
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Respiratory
No coughing nor shortness of breath.
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Eyes- she has no double vision, loss of vision, or blurred vision.
SOAP NOTE
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Name: DB
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Date: 1/13/2017
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Time: 10:33AM
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Age: 33
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Sex: Female
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SUBJECTIVE
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CC:
“My back hurts”.
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HPI: (Use OLDCART)
She reports feeling pain in her lower back that started yesterday while at work. Last night she went to sleep as usual, when she woke up this morning she was in a lot of pain and was very stiff. The pain is described as a 7/10 on the pain scale, feels like burning. Pt states pain is worse in the R lumbo-sacral area. Pain radiated to her R buttock. It hurts her to stand up or to find a comfortable position. Pain worsens after bending or lifting. Her back hurts even at rest, but gets worse with movement. Taking Tylenol 500mg 2 caplets with no relief of the pain. Denies hx of UTI symptoms; Denies vaginal discharge or dyspareunia; denies change in bladder or bowel habits; denies weight loss or fever. Denies hx of previous back pain, injury or trauma. States she works as a cashier at the grocery store where she stands most of the day. Yesterday was her second day of working over time at work and she thinks since she works standing up, this might have cause for her to feel pain in her lower back. Denies muscle weakness, paresthesia, loss of sensations, and no severe or progressive neurological deficit in lower extremity.
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Medications:
(list with reason for med )
Tylenol Extra Strength 500 mg Caplets, 2 tabs q4-6 hr for back pain with no relief
Metformin 500mg 1 PO QD for Type 2DM
Lisinopril 10mg 1 po QD for HTN
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PMH
Allergies: NKDA, denies food allergies
Medication Intolerances: Denies
Chronic Illnesses/Major traumas: HTN (2016), Type 2 NIDDM (2017)
Hospitalizations/Surgeries: Appendectomy (2001)
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Family History
States her parents (mother 59, father 63), siblings (sister 34, brother 27) and daughter- 4y/o are healthy and both sets of grandparents are alive and live in Colombia (doesn’t know age or if they have any medical problems).
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Social History
General: Born and raised in Cali, Colombia, moved to the US with her parents when she was 17 years old.
Marital status: Single Mom of a 4-yr/old girl. Ex-husband not involved financially or physic
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