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SOAP Note #3
Identification:
LP: 22 y.o Caucasian Female
Date of Visit: 02/17/17
BYU-Idaho Student Health Insurance
Subjective:
Chief Complaint: I am getting married and want a pre-martial physical.
History of Present Illness:
Pt states she is engaged to be married in April 2017. Denies any sexual
history. She was taking some birth control pills, Emoquette 0.15-30mg, to
treat acne in the fall 2016 but only took it for one month because after she
started taking them she noticed daily headaches (not migraines).
Pt states she is currently taking Accutane and seeing a dermatologist and
has a contract with them, would like lab work completed today to take to her
next appointment (lipids/triglycerides, liver function tests, and pregnancy
test) and reports she will stop acne treatment in April. Pt reports the
headaches decreased/stopped once she was off the birth control. Pt went to
the pre-martial class at BYU-Idaho and would like to start a birth control pill
today.
Past Medical History:
No seizures, no eating disorder, no heart disease, no substance abuse,
no history of abuse, no history of sexual assault or sexual abuse, no
migraine hx, no blood clot history.
Menarche: 14, periods occur monthly, flow lasts about 5-6 days,
moderate flow and minimal cramps. Pt uses tampons routinely.
Past Surgical History:
Adenoidectomy & tonsillectomy 2001.
Uvulectomy 2003.
Family History:
Mom: Anxiety, ADHD
Dad: Alive and Healthy
Siblings: None. Pt is an only child.
Allergies:
NKDA
None.
Medication:
Accutane 20mg/day
Social History: Pt is originally from Southern California. She met her fianc at
school and is excited for her upcoming marriage. She and her fianc are both
college students attending BYU-Idaho. She lives off campus in an apartment
complex. She has a vehicle. She does not have any pets. Her major is pre-
nursing and she enjoys working out. She does not have any pets. Denies
alcohol, drug, or tobacco use.
Immunizations: Up to date. Last influenza vaccine 10/2016.
Review of Systems
General: Pt reports she is overall healthy. Denies fevers, chills, sweats,
anorexia, fatigue, malaise, weight loss.
Eyes: Pt does not wear corrective lenses. Denies blurring, diplopia, irritation,
discharge, vision loss, eye pain, photophobia.
Ears/Nose/Throat: Denies earache, ear discharge, tinnitus, decreased
hearing, nasal congestion, nosebleeds, sore throat, hoarseness, dysphagia.
Cardiovascular: Denies chest pains, palpitations, syncope, dyspnea on
exertion, orthopnea, PND, peripheral edema.
Respiratory: Denies shortness of breath, cough, dyspnea, excessive sputum,
hemoptysis, wheezing.
Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, change in
bowel habits, abdominal pain, melena, hematochezia, jaundice.
Genitourinary: Denies vaginal discharge, incontinence, dysuria, hematuria,
urinary frequency, amenorrhea, menorrhagia, abnormal vaginal bleeding,
pelvic pain.
Musculoskeletal: Denies back pain, joint pain, joint swelling, muscle cramps,
muscle weakness, stiffness, arthritis.
Skin: Acne, currently tx with Accutane. Denies rash, itching, dryness,
suspicious lesions.
Neurologic: Denies transient paralysis, weakness, paresthesias, seizures,
syncope, tremors, vertigo.
Psychiatric: Denies depression, anxiety, memory loss, mental disturbance,
suicidal ideation, hallucinations, paranoia.
Endocrine: Denies cold intolerance, heat intolerance, polydipsia, polyphagia,
polyuria, weight change.
Heme/Lymphatic: Denies abnormal bruising, bleeding, enlarged lymph
nodes.
Allergic/Immunologic: Denies urticaria, hay fever, persistent infections, HIV
exposure.
Reproductive: Denies any sexual history.
Vital Signs:
Height: 65in.Weight: 135.8 lbs. KG: 60.60 BMI (in-lb) 22.68 BSA 1.68
BP: 118/80 SP02 : 94 Pulse rate: 98 Temp: 98.9 tympanic Pain:0/10
Physical Exam
General appearance: well nourished, well hydrated, no acute distress.
HEENT: Head: Normocephalic. Eyes: Pupils equal, round, reactive to light and
accommodation. Ophthalmoscopic: discs sharp and flat, no a/v nicking,
hemorrhages, or exudates. External ears: no lesions or deformities.
Otoscopic: canals clear, tympanic membranes intact with good movement,
no fluid Nose: pink nasalmucosa, septum, and turbinates pink. Pharynx:
tongue pink, posterior pharynx without erythema or exudate
Neck: supple, no masses, trachea midline
Thyroid: no nodules, masses, tenderness, or enlargement.
Cardiovascular: Clear to auscultation: S1, S2, no murmur, rub, or gallop
Respiratory: Auscultation: no rales, rhonchi, or wheezes.
Gastrointestinal: Flat soft symmetric appearance, BS active x 4 quadrants.
Genitourinary/ Reproductive: External genitalia: no lesions or discharge.
Vagina: no discharge, lesions. No evidence of cystocele or rectocele. Exam
Comments: Vaginal opening check: 1 finger easily inserted
Musculoskeletal: Gait and station: steady gait. +5/5 strength bilateral UE and
LE. Full AROM.
Skin: Inspection: no rashes, lesions, or ulcerations
Neurologic: Reflexes: 2+, symmetric, no pathological reflexes
Mental Status Exam: Mood and affect: pleasant.
Assessment:
1. Encounter for General Adult Medical Exam without Abnormal Findings
(Z00.00)
2. Encounter for general counseling and advice on contraception (Z30.0)
3. Screening for lipid disorders (Z13.220)
4. Screening for pregnancy test (Z32.00)
5. Screening for unspecified for disease or disorder (Z13.9)
6. Acne vulgaris (ICD-706.1)
Differential diagnosis: for Acne
Acne Conglobata
Acne Fulminans
Acne Keloidalis Nuchae
Acneiform Eruptions
Dermatologic Manifestations of Tuberous Sclerosis
Folliculitis
Perioral Dermatitis
Rosacea
Sebaceous Hyperplasia
Syringoma
Screening:
Routine screening lab work
To rule out Pregnancy prior to starting birth control.
Plan:
1. Encounter for General Adult Medical Exam Education:
Educated patient on importance of healthy diet and regular exercise.
6. Acne vulgaris
Pt will continue to see dermatologist for Accutane.