*NURSING > SOAP NOTE > soap note template | latest updated | all information included (All)

soap note template | latest updated | all information included

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Subjective CC: “I’ve had a white bump in the back of my throat for about 3-4 days that bothers me when I swallow.” History of Presenting Illness: Ms. A.T. is a healthy appearing 29-year-old,... Caucasian female, presenting with complaints of a “white bump” in the back of her throat that is bothersome when she swallows. The patient noticed “something was there” 3-4 days ago and asked her mother to look inside her throat, and she reportedly saw a “white bump.” Patient states the foreign body sensation is intermittent and present on the right side of her throat only when swallowing. Symptoms have neither improved nor worsened. Patient cannot recall if she ate food that caused throat irritation. She denies pain, recent illnesses, fever, chills, sore or scratchy throat, cough, nasal congestion, post-nasal drip, or ear ache, and states she feels “good except I feel it there every time I swallow.” Denies history of streptococcal throat infections. The patient denies using OTC medication, but gargled with warm salt water last night for the first time. The patient works as a sales associate at an eyeglass store and has not had contact with children recently. Medications: Nexplanon, right arm. Inserted 2016. Allergies: Denies medications, food and environmental allergies Previous Medical History: Denies Previous Surgical History: Denies Obstetric History:  Nulligravida Gynecologic History:  GYN: Pap 2/2017, Negative  Menses: o Menarche: 15-years-old o LMP: 5/29/17, light bleeding o Menses: Irregular with Nexplanon  Sexual History: o Sexually active with 4 lifetime sexual partners o Uses condoms  Contraceptive History: o Nexplanon  STIs: Denies [Show More]

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