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other concerns apart from those expressed at moment. Past Medical HistoryMedical history: Urinary tract infection(UTI) and yeast infection in 1994, Preeclampsia diagnosis in 2003 leading to her having a stillbirth, diagnosed with hypertension and hypercholesterolemia 2005, and post-partum depression in 2008 after the birth of her son. Denies having any diagnosis of heart disease or immune/blood disorder.Childhood illness: Otitis media and bronchitis in 1981, had hand, foot and mouth disease in 1983.
COMPREHENSIVE SOAP NOTE AND GENOGRAM4Immunizations: Received all childhood immunizations, takes the yearly seasonal flu vaccinations and don’t remember to have taken the 10 years tetanus and diphtheria booster (Td). She reported theTdap vaccine was given with her 2003 and 2008 pregnancies and denies to have taken the shingles vaccination. Surgical/Hospitalization history: Patient stated she had two surgeries, one for appendectomy in 1994 in Medical City Children’s Hospital Dallas and a C-section with the delivery of her son in 2008 in Texas Presbyterian Hospital Dallas. Allergies: Patient reports having some drug, food and seasonal allergies. She is allergic to penicillin, seafoods, peanut and pollens. Allergic symptoms include coughing, difficulty breathing, itching, watery eyes, rash, and sneezing. She takes antihistamines for seasonal allergies. She reports not to have suffered any severe or anaphylactic reaction that required treatment. Patient denies any known latex allergy.Current prescription and over the counter (OTC) medications:Lisinopril 20mg, 1 tab by mouth daily for high blood pressure. Lipitor 20mg, 1 tab by mouth once a day for hypercholesterolemia. Both medications lastly taken at 0800 today. Tylenol 325mg, 2 tab 4-6hours by mouth for headaches. Ibuprofen 200mg tab, 1-2 tabs 4-6hours by mouth as needed for pain. One a day women multi-vitamin, 1tab daily.Last Known Exam Dates:Her last physical was on 2/2018, blood pressure 136/94, and serum cholesterol level 365, LDL 204, HDL 32. Well women check breast exam, mammogram, pap smear, and pelvic exam done on 6/2019. Patient denies having a colonoscopy test done, lastly saw an optometrist and dentist a year ago. She can’t remember the last time she did a TB skin tests but her results have always been
COMPREHENSIVE SOAP NOTE AND GENOGRAM5negative. She has been sexually active but have maintained one partner her husband since 2003.Family HistoryLost paternal grandfather to lung cancer at age of 65 and grandmother died from hypertensive complications at age of 70. Maternal grandfather died of CHF in his 60s while maternal grandmother died of stroke at age 80. Her father suffers from cirrhosis due to him beinga heavy drinker and her mother suffers from Parkinson’s disease. Has a maternal uncle, 45 years of age currently undergoing dialysis due to kidney failure and a maternal aunt at age 35 with has diabetes. Patient’s brother and sister are of good health and she is not aware of any diagnosis.