Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Denies cough, wheezing, dyspnea at this time Eyes Corrective lenses Gastrointestinal De ... nies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears Denies ear pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Denies urgency, frequency burning, change in color of urine, vaginal discharge or STDS. Hysterectomy 5 years ago. Last mammography 1 years ago. G2, P2, A0 Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal Localized symptoms in hand joints: pain, tender, swollen, and decrease range of motion. Breast SBE every month, denies lumps, bumps or changes Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Heme/Lymph/Endo Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx OBJECTIVE Weight: 139 BMI: 23.9 Temp: 98.2 BP: 127/79 Height: 5’4 Pulse: 84 Resp: 16 General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Skin Skin is white, warm, dry, clean and intact. No rashes. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. This study source was downloaded by 100000816392744 from CourseHero.com on 04-21-2021 15:21:51 GMT -05:00 https://www.coursehero.com/file/30170766/SOAP-NOTE-Rheumatoid-Arthritisdoc/ [Show More]
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