This patient should be asked a scale of 010 how much these areas are bothering

This patient should be asked a scale of 010 how much

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there are any aggravating factors that cause discomfort with the areas. This patient should be asked a scale of 0/10 how much these areas are bothering or affecting her life. She should be questioned on if the areas have any weeping, crusting or ulcerate. She should also be asked if since noticing the areas have they changed over the past week. The patient should be asked if
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she has had any changes in detergents, soaps or uses douches at home. Also, if this patient has tried any medications or home remedies for these areas as well as any marked improvements is she has. The patient states that she has a history of asthma and chlamydia. She should be asked if she has any other history of STI’s that she is aware of. Her medication for asthma is incomplete as it does not give how often it is used. The PMH should also include is she has had any surgeries in the past. This patient SOAP needs to include her sexual/reproductive history which would include her menstrual history, methods of contraception, in depth look at her obstetric history with her risky sexual behaviors. Her personal/social history states her denial or tobacco use and occasional ETOH use but the patient should also be asked about any illicit drug use. The patient should also be questioned about her ADL’s, interests, exercise and eating habits. More details should be taken about this patient’s lifestyle including safety, support systems, sexual preferences and economic factors. There are no listed immunizations for this patient which should be addressed. In the subjective portion there should be a review of systems covering a head to toe, especially the systems in the chief complaints, present illness and history. The review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease (University of California, 2015). Additional Information Needed for Objective Portion The elements of the comprehensive H&P that are typically included as objective information in a SOAP note are as follows: vital signs, a general assessment of the patient, physical examination findings and results from laboratory or diagnostic studies (Sullivan, 2012). The patient’s temperature is normal, but it does not state where this was obtained. A blood pressure was obtained but it does not specify the arm and if the patient was sitting or standing.
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  • Fall '19
  • Sexual intercourse, Human sexual behavior, Human papillomavirus, lymphogranuloma venereum, Genital wart

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