Nursing 6551 - Week 7 Assignment SOAP Note.docx - 1...

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1EPISODIC SOAP NOTEEpisodic SOAP NoteWalden UniversityNURS 6551 – Primary Care of Women
2EPISODIC SOAP NOTEPatient Information:Initials: A. P. Age: 56Sex: FemaleRace: CaucasianSUBJECTIVE:Chief Complaint (CC): “I have a sore down there”History of Present Illness (HPI): 56-year-old Caucasian, married, femalepresents to the clinic today with complaints of labial pain and vaginaldiscomfort. She denies any bleeding or discharge. Onset: “For a long time” but worse over past 2 weeks agoLocation: labia- vaginaDuration: intermittently throughout dayCharacteristics: burning Aggravating Factors: urination, acidic foods, certain soapsRelieving Factors: NoneTiming: n/aSeverity: Can be debilitatingCurrent Medications: Ibandronate 150mg dailyPantoprazole 40mg dailyPravastatin 20mg dailySynthroid 112mcg dailyAllergies: Aspirin, Codeine, Coffee, Latex, Steroid, Tea, TomatoesPast 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 currentlyresides in her husband’s hometown. She is in a long-term relationship,heterosexual and is sexually active. She does not utilize contraceptives since
3EPISODIC SOAP NOTEher hysterectomy and has two grown children. She commutes to and fromwork by driving a motor vehicle. She reports the utilization of a safety beltwhile 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 anystrenuous activity. She is a former smoker and consumes alcohol on a dailybasis (1 glass of wine); denies illicit drug use. Her significant other is a greatsupport system. Family History: Mother – DM, Heart Disease, HTN; Father – DM, HeartDisease & Thyroid DisorderOB/GYN History: Menstrual History:Age at menarche – 13LMP – December 1, 2009Menstrual Pattern: 28-day cycleMenopause:January 1, 2010Contraception: Current method: NoneCervical & Vaginal cytology:Most recent pap - 4/2019History of abnormal pap smear – no historyInfections: No history of STIs, vaginitis or PIDSexual History: Heterosexual, relationship mutually monogamous No history of sexual abuse or assaultObstetric History: G – 2, P – 2, T – 2, A – 0, L – 0 Review of Systems:
4EPISODIC SOAP NOTEGeneral: No unexplained weight loss or gain, no decreased appetite, nochills, no fever or fatigue.HEENT: No blurred or loss of vision, no loss of hearing, hearing difficulty orringing in ears, no congestion, rhinorrhea, sore throat or hoarseness.

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