Patient has an eighteen year old daughter patient

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Patient has an eighteen-year-old daughter. Patient reports that her paternal aunty passed last year due to BR CA. Social History: Patient reports she has been married for the past 20 years and has monogamous relationship. She is sexually active with one partner, denies multiple partners in the past and denies the use of condom currently. Patient denies having any STDs or any risk factors for HIV. Patient denies the use of illicit drug use. She current works as Certified Nursing Assistant at Wingate at Andover MA Erikson: Generativity vs. Stagnation Patient report she take create delight in her work as she is able to help those who are vulnerable and need help. She reports being grateful for her life at this period, that she is able to give her daughter a better education than she got. Review of Systems: General: Patient report no acute distress. Patient denies having chills. Denies any sudden weight loss or gain. Denies having any unexplained bruising or bleeding. Able to do usual activities and report good state of health. Head and Neck: Patient head normocephalic and neck supple, no lymphadenopathy. Denies any head injuries or headaches. Eyes: Patient denies any vision changes. Ears: Denies any ear pain or discharge. Nose and Sinuses: Normal, denies any sinus complications or epistaxis. Mouth and Throat: Mucosa moist and denies sore throat, bleeding or swelling of the gums.
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SOAP NOTE Page 4 of 8 Skin, Hair, and Nails: Patient denies any open wound, rashes, masses, or lesions. Denies any changes to hair and nails. Chest and Lungs: Denies shortness of breath, dyspnea, wheezing, or coughing. Denies any pain related to respiration. Denies any hemoptysis, night sweats, or exposure to tuberculosis. Cardiovascular: Patient states some difficulty performing daily activities. Denies any chest pain, dyspnea, palpitations, and orthopnea. Breast : No history of lumps or tumors in breast area. Denies tenderness, discharge, or pain. Musculoskeletal: Repots neuropathy pain at bilateral lower extremities, weakness, joint stiffness at bilateral knee. Peripheral Vasculature : Repots neuropathy pain at bilateral lower extremities Lymphatic: No known lymph node enlargement or tenderness reported. Gastrointestinal: Denies nausea or vomitting. Denies any change in the color or content of stools. Reported bowel movements as “normal”. Endocrine: Denies thyroid enlargement or tenderness. Genitourinary: Denies a history of sexually transmitted infection. Denies pain, discharge, itching, or genital lesions. Denies urgency, frequency, hesitancy, dysuria, flank or suprapubic pain. Denies nocturia, hematuria, polyuria, or stress incontinence. Neurologic : Denies syncope, seizures, or tremors. Denies any numbness or tingling throughout the body.
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  • Fall '19
  • Diabetes mellitus type 2, Diabetic neuropathy, dyslipidemia

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