Walden UniversityNURS 6551Nursing 6551 - Week 11 Assingment SOAP Note
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1 EPISODIC SOAP NOTE Episodic SOAP Note Walden University NURS 6551 – Primary Care of Women Patient Information: 2 EPISODIC SOAP NOTE Initials: J. R. Age: 54 Sex: Female Race: Caucasian SUB... JECTIVE: Chief Complaint (CC): “I have been having some bleeding for the past week and I went through menopause 3 years ago.” History of Present Illness (HPI): 54-year-old Caucasian, widowed, female presents to the clinic today with complaints of vaginal bleeding for the past week. She has already reached menopause. Denies any other symptoms. Onset: One week ago Location: Vagina Duration: One week Characteristics: Vaginal bleeding Aggravating Factors: None Relieving Factors: None Timing: None Severity: “Does not bother me physically but it is annoying” Current Medications: Lisinopril 10mg daily Zoloft 25mg daily Allergies: No known allergies Past Medical History (PMH): Hypertension, Depression Past Surgical History (PSH): Colonoscopy (2016) Personal/Social History: Mrs. R was born in Maryland and currently resides in West Virginia to be near her children since her husband’s death a few years ago. She is in a long-term relationship, heterosexual and is sexually active. She does not utilize contraceptives since she experienced menopause 3 years ago. and has three grown children & four grandchildren. [Show More]
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