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NURS 6551, WEEK 7 SOAP NOTE 2 (CORRECT-FINAL) newest

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SOAP NOTE 2, WEEK 7 ASSIGNMENT-2 2 Patient Information: Initials: A. S. Age: 49 Sex: Female Race: African American SUBJECTIVE: Chief Complaint (CC): “I have a vaginal discharge for ten days.” History of Present Illness (HPI): 49-year-old African American female presents to the health care center for annual Pap exam with a complaint of moderate vaginal discharge for ten days. A.S. complains of vulvar itching, vaginal discharge, and pelvic pain started 7days ago. She complains that the pelvic pain gets worst and describes pain as “come and go shooting pain”, when she urinates or having a sexual intercourse. A.S. reports the pain scales as 7/8 during urination and 5/10 during intercourse. AS verbalizes the aggravating factor indicates a vaginal discharge that is constant, severe and describes the color as thick, copious mucous frothy foul smelling yellow-green discharge. AS verbalizes taking OTC medications Ibuprofen 400mg every 6 hours as needed for pain. The patient denies any relieving intervention for vaginal itching, no prior problems with similar symptoms, no abnormal bleeding, no fever, and no chills. Patient is sexually active 3-4 times a week with multiple partners and does not use condoms consistently. OB/GYN History: Menstrual History: Age at menarche – 12 years LMP – 11/15/2016 Menstrual Pattern: Cycle length: 28days Duration of flow: 5-6days Amount of flow: Moderate SOAP NOTE 2, WEEK 7 ASSIGNMENT-2 3 Associated pain: Menstrual cramp Intermenstrual bleeding: None Perimenopause/Menopause: Hot flash sometimes Contraception: Current method: None Previous methods: None Cervical & Vaginal cytology: Most recent Pap smear– 1/13/2016 History of abnormal Pap smear – Denies Mammogram- 6/5/2016 - Normal Infections: Denies any history of STI in the past No history of pelvic inflammatory disease Fertility/Infertility: Desire for future fertility: No Sexual History: Type: Heterosexual, sexually active, multiple partners relationship, unprotected sex Denies history of sexual abuse or assault Obstetric History: G – 4, P – 4, T – 4, A – 0, L – 4 Maternal, fetal, or neonatal complications: None

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