Walden University - NURSING: NURS6512 Health Assessment Week 10 discussion: SOAP NOTE Case Study #3. Graded A. SOAP NOTE

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Case Study #3 Patient Initials: __MH___ Age: _21____ Gender: __F____ SUBJECTIVE DATA: Chief Complaint (CC): External bumps on her genital area History of Present Illness (HPI): MH is a... 21-year-old Caucasian female who presents today with external bumps on her genital area. She says she is not sure how long they have been there but noticed them about 1 week ago. She denies pain and says the bumps feel rough. Medications: None Allergies: NKA Past Medical History (PMH): 1.) Asthma – when she was a child 2.) Chlamydia - 2014 Past Surgical History (PSH): None Sexual/Reproductive History: Heterosexual Initial sexual contact at age 18 Multiple sexual partners G0P0A0 Menarche age 13, cycles q 28-30, flow: 5-6 days. Mild dysmenorrhea; responds to ibuprofen. Last PAP 3 years ago and normal. Personal/Social History: She drinks occasionally; denied denies smoking or illicit drug use. Immunization History: Her immunizations are up to date. She received the influenza vaccine last October, and had a tetanus shot when she started her job last year. Significant Family History: No siblings. Both parents are living and healthy. Lifestyle: She lives at home with her parents in a nice neighborhood with a low crime rate. She says she exercises most days. She says she smokes about a half a pack of cigarettes a day. She has a primary care nurse practitioner provider and goes for her yearly checkups and when she is sick. She had a PAP smear done three years ago. She has not had a mammogram, and does not do monthly self-exams. She is sexually active and has had more than one partner over the last year. She says she tries to eat healthy but does eat out a few times a week at fast food restaurants. She has a good support system composed of family and friends. OBJECTIVE DATA ASSESSMENT: Lab Tests and Results: Biopsy of tissue from the suspicious skin area Reference American Academy of Dermatology (AAD). (2016). Mollucsum contagiosum. Retrieved from https://www.aad.org/public/diseases/contagious-skin-diseases/molluscum-contagiosum AVERT. (2015). Genital warts. Retrieved from http://www.avert.org/sex-stis/sexually-transmitted-infections/genital-warts-hpv Centers for Disease Control and Prevention. (2016). Genital herpes – CDC fact sheet. Retrieved from http://www.cdc.gov/std/herpes/stdfact-herpes.htm Cure Hidradenitis Suppurativa. (2016). Hidradenitis suppurativa groin. Retrieved from http://www.curehidradenitis.com/hidradenitis-suppurativa-groin/ Nall, R. (2016). Genital warts. Retrieved from http://www.healthline.com/health/std/genital-warts#Overview1 Simple Remidies. (2011). Symptoms of ingrown hair on pubic area and its treatment. Retrieved from http://www.simple-remedies.com/hair-care/ingrown-hair-on-pubic-area.html [Show More]

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