Womens health soap note 1

Please provide the requested information on the template and enter the information on the template form attached.

patient: 38 year old white female

chief complaint: annual pap smear

history of present illness: annual pap smear, was on menstrual cycle last week and unable to complete pap at last visit. Pt denies any complaints today.

history: +HPV in 07/2023 with colposcopy done, CIN 1 benign,Near-sighted. Retinal exam 4/15/2024

-some social history, please add more:

Alcohol: occasional alcohol use, one time a month

Exercise: daily exercise, get at least 12,000 steps a day

Marital Status: single, one male child age 10

Working status: Business owner, owns a boutique

Diet: currently on a regular diet, eats a lot of vegetables

Active Medications:

Buspirone Hcl 30MG Tablet

Lexapro 20MG Tablet

Desvenlafaxine Succinate Er 25MG Tablet Extended Release 24 Hour

Drug Allergies:

Zoloft Symptoms: rashes.

Food Allergies:

Fish Symptoms: rashes, abdominal discomfort, Diarrhea, Nausea, Vomiting.
No Known Environmental Allergies.

Vital signs

Temperature 97.5

Heart rate 64

respiratory rate 17

Blood pressure 111/65

O2 sat 97%

Weight 135.4 pounds

ICD code: z11.51, z 12.4

LABS:

Test/Orders:THINPREP TIS PAP AND HPV mRNA E6/E7

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