NURS6512+Ruskamp+Rachel .docx - Initials:ABAgeduringthevisit:21y\/oFemale SD ChiefComplaint(CC: (HPI HPI:AB,WFcollegestudent,

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SOAP Note Analysis Week 10  SOAP Note Analysis Week 10   Initials:   AB      Age during the visit:  21y/o            Female  SD: Chief Complaint (CC): Self -reports “ bumps on my bottom that I want to have checked out.” History of Present Illness (HPI):  HPI: AB, WF college student,  21-year-old reports to the clinic with visible bumps on her genital area, bumps are reported painless and but feel rough. She indicates she reports that she is  sexually active with multiple partners. Initial sexual intercourse was reported to have occurred at  age 18. Patient reports no abnormal vaginal discharge and is unsure when the bumps may have  originated. She reports noticing the bumps x7 days. Her last well women’s exam completed three years ago, and the exam results were normal. She reported a history of one sexually transmitted  infection (chlamydia) about two years ago, and she completed the treatment for chlamydia as  prescribed. Onset  -Noticed bumps x 7 days; remains uncertain how long they have been there.  Please describe the bumps for me in more detail (color, shape, size, pattern, etc.). Have you  noticed bumps before seven days ago or episodes of discomfort related to the bumps in the past?  When did you see them before, and any treatments necessary to relieve the pain? 
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Any recent illnesses or fevers or anyone in your home been ill?  Have you had any current  surgical procedures requiring anesthesia or new medications that you recently began taking?  Are these bumps like comparable to the symptoms you experienced two years ago when you  Chlamydia in your PMH? Location  -  bumps located external genitalia Are these bumps contained to just the genital area? Can you tell if any are internal or just  external on your vagina?  Description  - Painless and feel rough Any experienced any vaginal itching or burning with urination before noticing the bumps?  Also, noticed that the bumps ulcerate, drain fluid or crust?  Have the bumps spread?  Changes  -Uncertain about the day of onset, but reports noticing the bumps x7 days ago.     Initially, how did you notice the bumps initially?   Assessment–  Are you aware of anything that aggravates the bumps or increases in size, shape or  amount?  Do you shower daily with antibacterial soap or recently changed laundry detergent?  Treatment   –  tried any home remedies or topical medications and did you see any improvement or changes in the bumps?  Symptoms  –  painless bumps upon assessment.    Pain is 0/10, rate how the bothersome the bumps are to everyday life, 10 being the most  significant effect?
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  • Summer '15
  • et al., chlamydia, Medical diagnosis, PAST SURGICAL HISTORY, Symons, bumps

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