Lataille.Week7.SOAP - Laura 40yo F S CC fatigue weight loss nausea changing skin color HPI Laura has been feeling bad for a few weeks now thought it was

Lataille.Week7.SOAP - Laura 40yo F S CC fatigue weight loss...

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Laura, 40yo, F S. CC- fatigue, weight loss, nausea, changing skin color HPI- Laura has been feeling bad for a few weeks now, thought it was the flu. She denies fever but has been nauseous. Now she notices her skin color has a funny tinge to it. She reports decreased appetite and nausea for 3 weeks; she has lost 5 pounds, muscle aches and stomach cramps. She has taken Ibuprofen for her aches and pains but no other OTC medications. Current medications- daily multivitamin, fish oil, and CoQ 10 Allergies- Penicillin (rash) PMH- Reports general health as good. Was exercising regularly and very active until onset of these symptoms. Childhood illness - chicken pox Surgeries- cholecystectomy, total abdominal hysterectomy Hospitalizations- childbirth x 2 Immunizations- Does not receive the flu shot. Soc Hx- ETOH, tobacco, illicit drugs. She drinks alcohol socially, does not smoke, denies illicit drug use. Sleeps 6 to 8 hours per night. Divorced for 2 years, dating for 1 year. She is sexually active with 2 partners in the last 6 months. Does not use condoms, had a BTL 10 years ago. Family Hx- Parents are alive in good health. She has 2 daughters in good health. O. PE: VS: Height 5 feet 9 inches. Weight 150 pounds BP 126/76. T 98.0, P 72, R 12 BMI 22.2 (Normal BMI) General: Caucasian female in no apparent distress, appears stated age. Alert, oriented and cooperative, appears fatigued. Skin: Skin warm, dry, and intact. Skin color is slightly jaundiced. No moles noted. No track marks noted. HEENT: Head normocephalic. Hair thick and distribution even throughout scalp Eyes: .Sclera clear. Conjunctiva: icteric, PERRLA, EOMs intact
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Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender
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