Running Head: Week 3 SOAP Note 1 Week 3 SOAP Note Wauneta Armstrong NURS 6551D-2/NURS-6551N-2 Primary Care of Women September 8, 2018 Week 3 SOAP Note 2 `Age: 30 Gender: F SUBJECTIVE DATA: Chi... ef complaint: Irregular periods and left breast is enlarged and painful at times, getting more acne. History of Present Illness (HPI): 14-year-old Caucasian female presents to the clinic today with concerns for irregular periods for one year. Started menses at age 11. Cycles have always been irregular. Will skip 3-4 months at a time. When the period begins she describes them as very heavy. Has to change pad every 1 to 2 hours. Does not have clots. Has “bad, bad” cramping. Menses last 8-9 days when she does start. Left breast is enlarged with intermittent pain. Weight gain and unable to lose weight. Acne has also worsened in the last six months. Medications: No current medications Allergies: NKDA, no environmental or food allergies Past Medical History (PMH): None Past Surgery History (PSH): None [Show More]
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