Question 16 (2 points) Saved Since behavior analysts operate in
USE THE TEMPLATE BELOW TO MAKE EPISODIC VISIT SOAP NOTE FROM NIKKI’S CASE STUDY PATIENT PRESENTATION: Identifying information: Nikki is 29 y/0 non-binary G1P0010. Nikki uses feminine language in reference to her body and she/her pronouns. Reason for the visit: Irregular periods PATIENT HISTORY: HPI: Her LMP was 8 weeks ago, which is the longest time between cycles that Nikki has ever experienced. Reports discontinuing OCPs about 6 months ago and has gotten 3 menstrual cycles since stopping. Periods have been irregular since menarche, when not on OCPs. Cycle length every 36-40 days, lasting 2-7 days. Sometimes heavy bleeding and cramping for up to 7 days. While on OCPs cycles were “usually regular, about every 4 weeks, lasting 3-4 days” and medium flow. Stopped OCPs due to concerns that she was gaining weight, about 10 lbs in past two years. She doesn’t know why her periods are so spaced out. Past medical hx: Acne Current Medications: Multivitamin, topical retinol Surgical hx: Wisdom tooth extraction – no complications. OB/GYN Hx: G1P0010. SAB 5 years ago at 3 months. Menarche at age 11. Last Pap 2022 negative with neg HPV; no STI history. Sexual hx: Bisexual. Has current partner, female x 3 yrs, monogamous: 10 partners lifetime. Does not use barrier method with current partner. Satisfied with sex life. Family hx: Mother: Obesity, Type II DM Dad: HTN MGM: colon cancer Social hx: Lives with long-term partner. Denies marijuana and cigarette smoking. Has one alcoholic drink a day with dinner. Denies illicit drug use. Works full-time as a receptionist at a salon. OBJECTIVE DATA: Vital Signs: BP: 138/86 Oral temp: 97.5 HR: 88 RR: 18 O2 sat: 99% on room air BMI 42 5’4″ 245 lbs REVIEW OF SYSTEM: – FOCUS ON HPI & DIFFERENTIALS Constitutional Denies fever, chills Denies heat and cold intolerance Cardiovascular Denies heart palpitations Respiratory Denies SOB Skin Reports acne History of hirsutism, has had laser hair removal to chin and upper lip GI Denies nausea or vomiting Denies abdominal pain, cramping Denies constipation or diarrhea GU Denies flank, back, or side pain Denies dysuria, frequency or urgency, hematuria Reports irregular menses when not using OCP Psychiatric Denies depression & anxiety PHYSICAL EXAM: General: Alert, oriented x 3, well-nourished, calm and answers appropriately HEENT: Normocephalic, symmetrical, no signs of trauma, acanthosis noted on neck, Thyroid smooth, symmetrical, not enlarged, no masses palpated. Heart: No murmurs, regular rate, S1 and S2 Lungs: Breathing unlabored, lung sounds clear to auscultation bilaterally Abdominal: non tender, no guarding, no masses or organomegaly. Normal bowel sounds Skin: mild acne to face and back, acanthosis on neck. No other lesions, no bruising noted. Extremities: No edema, no varicosities, normal gait WHAT ARE YOUR ASSESSMENT? What are your working diagnosis? Remember the reason for the visit May include normal and/or abnormal conditions Include all diagnoses addressed at visit Include the ICD-10 codes consisted with each dx THE PLAN Must include treatment, education, & follow-up Requires shared decision-making Driven by the working or find diagnosis/diagnoses Episodic Visit SOAP NOTE Date and time: SUBJECTIVE CC (Chief Complaint/Reason for visit): In patient’s own words HPI: (History of Present Illness) ___ y/o G P (TPAL) complains of/reports (BOLDCARTS) Current medications: Allergies: PMH: Past Medical history: (choose pertinent systems) Medical: Surgical: Obstetric Hx: GYN Hx: Psychiatric Hx: Family history: Social history: Health maintenance (PCP, immunizations, etc.) ROS (Review of Systems): (choose pertinent systems) OBJECTIVE Vital Signs: Wt, BMI, BP, HR, RR, Temp General Survey Targeted Physical Exam: ASSESSMENT (with ICD-10 codes) Episodic problem= diagnosis Chronic Health problems= diagnosis PLAN: Treatment: Medications & lifestyle changes: Diagnostic testing: Consultation/Coordination of care: Patient and family education: (as appropriate) Follow up: Resources used (For learning purposes please include at least one appropriate evidence-based clinical resource to support your plan) :
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