UNIT 5 Lab Assignment Amenorrhea SOAP NOTE, 2020 A+ Grade

CHIEF COMPLAINT (CC): Patient states she has not had a period in 3 months. Patient states she does not believe she is pregnant but is unsure of what is going on. HISTORY OF PRESENT ILLNESS (HPI): Patient presents today with complaints of no period for 3 months. Patient states last period was around Christmas, about the time she broke up with her boyfriend. Patient states she was sexually active, using condoms for birth control intermittently. Patient reports periods have always been irregular, occurring approximately every 1 to 4 months. Patient states she has noticed an unintentional 20-pound weight gain but denies changes in appetite. Patient states the skin on her neck appears darker and may feel “a little thicker”. Patient states the hair on her face is increasing and getting darker. Patient reports acne is also getting worse. PAST HISTORY PMH: Patient denies any past medical history or illness. Patient reports she is “really healthy”. PSH: Denies any prior surgeries or procedures. PSYCHIATRIC HISTORY: Patient denies any feelings of sadness or depression. States she is generally a “pretty happy person”. Patient denies any mood disorders, psychiatric treatment, or hospitalizations. FAMILY HISTORY / SOCIAL HISTORY FAMILY HISTORY (FH): Patient states both parents are alive and well. Patient reports neither parent has any health issues. She reports all 4 of her grandparents “died of old age”. Patient has an older sister who has no known health issues. Patient denies knowledge of any familial diseases. SOCIAL HISTORY: Patient states she recently broke up with her boyfriend of 1 year approximately 3 months ago. Patient states she was sad at first but is doing ok now. Patient reports she keeps busy with her friends, school and exercising. Patient states she is a full-time student pursuing a degree in speech pathology. MEDICATION RECONCILLIATION / REVIEW MEDICATIONS & INDICATIONS: (Prescribed & OTC) Patient states she takes a multivitamin daily. Denies use of any other prescription or OTC medications. ALLERGIES / IMMUNIZATIONS ALLERGIES: Patient denies any medical or environmental allergies. Patient denies any food allergies or food intolerances. IMMUNIZATIONS: Patient states to her knowledge, all her immunizations are up to date. Patient reports she receives Influenza vaccinations each year and has already had her flu vaccine this season. HEALTH PROMOTION / HEALTH MAINTENANCE