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HS 111 HS111 HS/111 Unit 5 SOAP Note

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HS 111 HS111 HS/111 Unit 5 SOAP Note

01/15/15: S: Pt is 28 yr old F. History of IUD 2012. 2014 Pt seen for dysmenorrhea and menometrorrhagia with diagnosis of oophoritis, hematosalpinx with multiple myoma.

Pt in ER presents c/o myalgia, episodes of syncope, fever, rash over face and chest, N and V x 2 days, and leukorrhea.

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HS 111 HS111 HS/111 Unit 5 SOAP Note

01/15/15: S: Pt is 28 yr old F. History of IUD 2012. 2014 Pt seen for dysmenorrhea and menometrorrhagia with diagnosis of oophoritis, hematosalpinx with multiple myoma.

Pt in ER presents c/o myalgia, episodes of syncope, fever, rash over face and chest, N and V x 2 days, and leukorrhea.

Pt experiencing dysmenorrhea x 5 days and diarrhea started today. O: T: 100.7, P: 96, R: 22, W: 155, H: 5’6, BP: 105/62. Pt LOC, extension weak.

Lungs clear. Cardio S1 and S2 normal limits. Urine obtained, 100 ml cloudy, dark amber in color. Lab: CBC. WBC, Creatinine, BUN, UA, Vaginal, Throat and Urine cultures

HS 111 HS111 HS/111 Unit 5 SOAP Note

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