Question Answered step-by-step Create a SOAP note based on a FOCUSED Exam. Chief complaint: “I am… Create a SOAP note based on a FOCUSED Exam. Chief complaint: “I am here to have my Nexplanon removed”. History of Present Illness: A twenty-three-year-old white female, G0, obese presenting for Nexplanon removal. This implant has been in place in her left arm since August of 2017, however, she desires its early removal due to unintended weight gain and increased appetite, as well as uncontrollable mood lability. She does complain of symptoms suggestive of yeast infection. She has had recurrent yeast infections to the vulva and vagina area, otherwise she is doing well Past Medical History: chronic headaches, dizziness, obesity, and recurrent yeast infections Surgical History: She reports having a genitourinary surgery, she has no details. She reports having an endoscopy in November 2017 to evaluate gastritis. Allergies: Cephalosporins – rash Medications: No routine medicationsSocial History: She is single and lives at home with her parents. She works at an area convenience store as a cashier. She denies the use of tobacco products or illicit drug use. She reports she occasionally has a drink when she is out with friends. She denies any hobbies. She reports occasional intake of caffeine by way of soda and sweet tea. She reports no history of sexually transmitted infections. Family History:Father – 44yo, alive with no medical issuesMother – 43yo, alive with no known medical issuesmaternal grandmother – 63yo, is alive with HTNmaternal grandfather – 65yo, is alive with HTN, CVD, and PVDpaternal grandmother – deceased at 62yo secondary to a massive myocardial infarction paternal grandfather – 63yo, alive with HTN, CAD, nicotine addiction Health Maintenance/Promotion: She reports that she is current on childhood immunizations. She reports pap smear a at the age of 21 – no abnormal cells noted. She has had no other immunizations since she finished high school. She has not seen an eye doctor in the last five years, and she does not visit a dentist on a regular basis having not been in the past three years. She does not perform regular self-breast examinations. Review of Symptoms General: Reports a weight gain of 27 pounds since she had her Nexplanon inserted. She denies fatigue, fever, chills, or night sweats. Skin: Reports itching in her groin area. Denies rashes, lesions, dryness, moles, or hives. She denies nail bed color changes, breast pain, lumps, or nipple discharge. HEENT: Denies headaches, or hair texture change. She denies blurred vision, spots, dizziness, eye redness, irritation, or drainage. She denies facial/sinus pain. Denies ear pain, hearing loss, vertigo, or drainage from ears. Denies nasal drainage, epistaxis, or difficulty with smell. Denies dry mouth, sore throat, hoarseness, or snoring. She denies mouth, tongue, or teeth pain, denies mouth ulcers, dry mouth, or chewing and swallowing difficulties. Denies bleeding gums. Denies knowledge of dental caries. Neck: Denies neck or shoulder stiffness or swelling. CV: Denies chest pain, chest tightness, orthopnea, and palpitations. Lungs: Denies dyspnea, shortness of breath, cough, wheezing, bronchitis, asthma, sputum production, or hemoptysis. GI: Denies heartburn, dysphagia, nausea, or vomiting. Denies diarrhea, constipation, black or bloody stools or changes in bowel patterns. Denies abdominal discomfort or distention. Conveys she has no food preferences and consumes a regular diet three times daily. GU: Reports vaginal itching and a white discharge. Denies dysuria, hematuria, frequency, or abnormal bleeding. Denies flank pain. Denies history of any sexually transmitted diseases. Reports recurrent yeast infections. PV: Denies varicose veins, temperature changes, edema, tingling, numbness, or discoloration to upper and lower extremities. MSK: Denies mouth, neck, jaw pain, back pain, or muscle stiffness. Denies difficult walking or climbing stairs. Denies decrease in range of motion. Neuro: Denies headache, dizziness, blackouts, tremors, weakness, numbness, speech problems, memory loss, loss of consciousness, or seizures. Endo: Reports increase in appetite. Denies excessive thirst. Denies hot and cold intolerance. Psych: Denies depression, anxiety, or suicidal ideations. Denies sleep disturbances. Objective:General: A 23-year-old morbid obese white female, healthy in appearance whom is well developed, well nourished, and well groomed. She appears in no acute distress. Ambulation noted to be normal. She is alert and orient to person, place, time and situation. VS: Temp-97.4*F (orally), B/P-128/80 sitting-L arm, HR-97 with regular rate, RR-20, Pulse Ox-97% on Room Air at rest.Weight – 353lbs, Height – 5′ 8″ with a BMI of 53.7 Skin: Round symmetrical face without atrophy. Warm and dry skin. Appropriate turgor with good elasticity noted, no tenting. Erythema of skin noted to bilateral inner thigh areas, below lower breast area, and between abdominal skin folds. No ulcerated areas noted. Fingernails pink. Breast: Pendulous, no masses, no nipple dischargeHEENT:Head: No tenderness, lesions, or evidence of trauma, evenly covered with black shoulder length hair.Eyes: The pupils are equally round and reactive to light and accommodation at 3mm bilaterally and non-injected. Ears: No abnormality of external ears appear noted. The external auditory canals have no drainage present, the auricles are symmetrical. Tympanic membranes are pearly gray and landmarks are identifiable.Nose: There are no external lesions, nares are patent and nasal turbinates are pink with no drainage. Midline septum. There is no frontal or maxillary sinus tenderness.Throat: There are no mouth, lip, or gum ulcers and no bleeding gums. Visible hard palate. No throat drainage and no erythema. Tonsils visible. Neck: Trachea is midline, no thyromegaly. There is full range of motion of neck and shoulders. There is no tonsillar, deep cervical, or posterior cervical node tenderness. No carotid bruits heard on auscultation. CV: There is normal S1 and S2 present with a regular rhythm and rate. There are no murmurs, rubs, or gallops.There is no lower peripheral edema, clubbing, or cyanosis present and no calf tenderness. Lungs: Symmetrical chest expansion, no dyspnea, lungs clear to auscultation. There is no chest wall tenderness. ABD: Large, soft, no tenderness, guarding, hernias or masses, no hepato or splenomegaly present. Hyperactive bowel sounds present times four quadrants. There are no femoral or renal artery bruits auscultated. GU: Erythema noted of skin inner and outer vaginal opening as well as the entire vulva area. There is no costovertebral tenderness. PV: Palpable peripheral pulses. There is quick capillary refill, no clubbing noted. There is no swelling to upper or lower extremities. No varicosities. No temperature changes between upper and lower extremities. MSK: Full ROM with normal gait and station. No deformities, normal curvature of back and no tenderness. Normal tone and motor strength. Neuro: Motor is 5/5 throughout. Bilateral hand grip equal and strong. Psych: Good insight and judgement, Normal mood and affect, active and alert. Normal speech, tone, and voice. Health Science Science Nursing NU MISC Share QuestionEmailCopy link Comments (0)