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Running Head: Week 11 SOAP Note1Week Eleven SOAP NoteHannah ReevesWalden UniversityPrimary Care of WomenMay 7, 2019
Week Eleven SOAP Note2Age: 26Gender: FemaleSUBJECTIVE DATA:Chief complaint: “I have a sore on my labia.” History of Present Illness (HPI): This 26-year-old female presents to the clinic complaining of a singular raised area on her genitals. She does not have a history of STDs, but she had sex with someone new approximately 2 weeks ago and she is not sure of his sexual history. She denies any other accompanying symptoms and explains that the area is not painful or tender to the touch. She denies observing any changes to her normal vaginal discharge and has been afebrile. Location: Inner aspect of the labia minoraOnset/Duration: Approximately two weeks agoCharacter: Painless Associated Symptoms:Patient reports that she has not noticed any other symptomsTreatments: None Eliminates/Aggravates: N/ALast Menstrual Period (LMP- 3-21-2019) Gravida (1), Para (1), Abortions (0), Miscarriages (0), Live births (1), premature births (0)Allergies: LatexPast Medical History: None significant to CC. Significant Family History:Mother:Hypertension, Breast CA Father:Obesity, Type II DMSibling:NoneM.G.M.Type II DM, bilateral BKA M.G.F.CADP.G.M.Unknown
Week Eleven SOAP Note3P.G.F. Deceased of MI Past Surgery History (PSH):Appendectomy 2011Personal/Social History:Tobacco Use:½ pack daily x 5 years Smokeless Tobacco:NONEPassive Smoke:Daily Drug Use:NONEHIV risk:Patient admits that she does occasionally have sex with people thatshe doesn’t know that well, but she uses condoms “most” of the time. Caffeine use:Daily Alcohol Use:Drinks beer 3-4 times a month Seatbelt Use:AlwaysSun Exposure:Frequently in summer Current Medications: Ibuprofen 400mg for occasionally for menstrual cramps or headacheNuvaRing for contraceptionReview of Systems (ROS): HEENT: Patient denies decreased visual acuity or hearing impairment. Denies sore throat. Neck: Denies nuchal rigidity, limited ROM of neck, or difficulty swallowing. Cardiovascular/Peripheral Vascular:Denies syncope or dizziness. Denies ever experiencing edema, chest pain, or palpitations. Respiratory:Denies difficulty breathing at rest, but she reports that she does become short of breath at times when she is doing physical activity. She relates this to her smoking history and sedentary lifestyle. Gastrointestinal: Denies a frequent dyspepsia. Denies hematochezia or trouble passing stool. Reports that she has a bowel movement at least every other day.Breast: Patient reports that she has never noticed any breast issues. She does frequent self-breast exams routinely d/t her mother’s history of breast CA.