Last eye exam was in 2014 No history or report of eye pain itching glaucoma

Last eye exam was in 2014 no history or report of eye

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Last eye exam was in 2014. No history or report of eye pain, itching, glaucoma, cataracts, diplopia, floaters, excessive tearing, or photophobia. No recent change or loss in hearing, ear infections, tinnitus, or drainage from the ears. A.B. cannot recall her last auditory evaluation. A.B. reports an intact sense of smell. No history of polyps, rhinorrhea, itching, or sinus problems. Last dental exam was 9/2017 and denied any complaints of gingivitis, bleeding gums, ulcerations, or lesions. A.B. denies any use of dentures or dental appliances. A.B. has no difficulty chewing or swallowing. Neck: No report of pain or limited range of motion. Respiratory: No complaints of dyspnea, cough, or hemoptysis. Denies history of pneumonia. Date of last PPD and chest x-ray is unknown by patient. CV: No complaints of chest discomfort, palpitations, edema, dyspnea upon exertion or claudication. Denies history of murmur, arrhythmias, orthopnea, and paroxysmal nocturnal dyspnea. GI: No nausea, vomiting, or reflux. No abdominal pain, no changes in bowel/bladder pattern.
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COMPREHENSIVE SOAP 5 GU: No change in urinary pattern or urine stream. No reports of dysuria, vaginal discharge or itching. A.B. is heterosexual and has a history of multiple sexual partners in the last year and a chlamydia diagnosis in 2016; resolved with antibiotics. Painless rough bumps present in genital area. A.B.’s children were conceived without fertility assistance. MS: No history of trauma or fractures. No complaints of arthritis, joint swelling gout, limitation in range of motion, or arthralgias. Psych: No history of anxiety or depression. Denies suicidal and homicidal histories. No history of delusions or mental health history. Neuro: No history of seizures, syncope, numbness, tingling, or weakness. No change in coordination or gait. No change in memory or thinking patterns. Integument/Heme/Lymph: No reports of rashes, pruritus, or bruising. She has no history of skin cancer or other skin lesion removal. No history of bleeding disorders, clotting difficulties, or blood transfusions. Endocrine: No intolerance to temperature, polyuria, polydipsia, polyphagia or changes in hair and skin texture. No hormone therapies. Allergic/Immunologic: Denies history of food allergies. No history of allergic rhinitis or asthma. Last HIV test was 2017 and was negative. OBJECTIVE DATA Physical Exam: Vital signs: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169 lbs General: 21 yo WF, appears in no immediate distress or discomfort. AAOx3
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COMPREHENSIVE SOAP 6 Heart: RRR, no murmurs Lungs: CTA, chest wall symmetrical Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia.
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  • Summer '15
  • Human Sexuality, Human sexual behavior, Syphilis, Sexually transmitted diseases and infections, Genital wart

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