SOAP Presentation
Transcript: Becky Rene Salgado Subjective Data 55 year old Pronounce: She/Her/They March 16, 2023 at 3:00 am. CC: Chest Pain "squeezing & tightness" 4/10 Pain Scale Better: deep breathing Worst: more stress & over-fatigue Pt states having intermittent headaches for several days Personal Health Hx Personal Health Hx Occupation: Marine Veteran and the Director of Operations in the Foothill De Anza Community College Surgical Hx: Gastric bypass, Umbilical hernia, removal of tonsil and adenoidectomy Past Medical Hx: Colon polyps Degenerative disc disease DM type 2 Diverculosis GERD Hemorrhoids Peripheral Edema Hx of Alcohol Use Disorder Hyperlidemia Hypertension Migraine Obstructive Sleep Apnea Tinnitus Family Hx Social Hx Family Hx Maternal Grandfather: CAD, MI, and multivessel CABG and stenting Mother: "heart issues" Social Hx Lives in San Mateo County Pt denies tabacco alcohol and drug use Review of Systems Lifestyle & Health Practices Review of Systems Denies: Palpitations, SOB, leg pain or swelling (based on her chief complaint) Denies: dizziness, lightheadedness, sore throat, nasal congestion, and rhinorrhea Lifestyle & Health Practices Declines: Mood/emotional distress Lack of concentration Poor appetite Tired waking up Sedentary Objective Data OUR OFFICES OUR OFFICES London San Francisco Brussels New York Beijing Houston Hong Kong PRODUCTS Assessment PRODUCT #1 PRODUCT #1 PRODUCT #2 PRODUCT #2 PRODUCT #3 PRODUCT #3 Planning PRICING Click to edit text SOAP CONTACT US