NURSING > SOAP NOTE > Walden UniversityNURS 6551Nursing 6551 - Week 7 Assignment SOAP Note. (All)

Walden UniversityNURS 6551Nursing 6551 - Week 7 Assignment SOAP Note.

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1 EPISODIC SOAP NOTE Episodic SOAP Note Walden University NURS 6551 – Primary Care of Women 2 EPISODIC SOAP NOTE Patient Information: Initials: A. P. Age: 56 Sex: Female Race: Caucasian SUBJECTIVE: Chief Complaint (CC): “I have a sore down there” History of Present Illness (HPI): 56-year-old Caucasian, married, female presents to the clinic today with complaints of labial pain and vaginal discomfort. She denies any bleeding or discharge. Onset: “For a long time” but worse over past 2 weeks ago Location: labia- vagina Duration: intermittently throughout day Characteristics: burning Aggravating Factors: urination, acidic foods, certain soaps Relieving Factors: None Timing: n/a Severity: Can be debilitating Current Medications: Ibandronate 150mg daily Pantoprazole 40mg daily Pravastatin 20mg daily Synthroid 112mcg daily Allergies: Aspirin, Codeine, Coffee, Latex, Steroid, Tea, Tomatoes Past Medical History (PMH): Depression, hypercholesterolemia, hypoglycemia, GERD, Thyroid Disorder, Constipation, Arthritis, Hemorrhoids. Past Surgical History (PSH): Colonoscopy (2013), EGD (2013), Hysterectomy (2010), Lap cholecystectomy (2014). Personal/Social History: Mrs. P was born in West Virginia and currently resides in her husband’s hometown. She is in a long-term relationship, heterosexual and is sexually active. She does not utilize contraceptives since 3 EPISODIC SOAP NOTE her hysterectomy and has two grown children. She commutes to and from work by driving a motor vehicle. She reports the utilization of a safety belt while driving and does not use her mobile device while driving that vehicle. She walks with her husband in the evening on occasion but does not do any strenuous activity. She is a former smoker and consumes alcohol on a daily basis (1 glass of wine); denies illicit drug use. Her significant other is a great support system. Family History: Mother – DM, Heart Disease, HTN; Father – DM, Heart Disease & Thyroid Disorder OB/GYN History: Menstrual History: Age at menarche – 13 LMP – December 1, 2009 Menstrual Pattern: 28-day cycle Menopause: January 1, 2010 Contraception: Current method: None Cervical & Vaginal cytology: Most recent pap - 4/2019 History of abnormal pap smear – no history Infections: No history of STIs, vaginitis or PID Sexual History: Heterosexual, relationship mutually monogamous No history of sexual abuse or assault Obstetric History: G – 2, P – 2, T – 2, A – 0, L – 0

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