Assign11ReevesH. SOAP3.docx - Running Head Week 11 SOAP...

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Running Head: Week 11 SOAP Note 1 Week Eleven SOAP Note Hannah Reeves Walden University Primary Care of Women May 7, 2019
Week Eleven SOAP Note 2 Age: 26 Gender: Female SUBJECTIVE 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 minora Onset/Duration: Approximately two weeks ago Character: Painless Associated Symptoms: Patient reports that she has not noticed any other symptoms Treatments: None Eliminates/Aggravates: N/A Last Menstrual Period (LMP- 3-21-2019) Gravida (1), Para (1), Abortions (0), Miscarriages (0), Live births (1), premature births (0) Allergies: Latex Past Medical History: None significant to CC. Significant Family History: Mother: Hypertension, Breast CA Father: Obesity, Type II DM Sibling: None M.G.M. Type II DM, bilateral BKA M.G.F. CAD P.G.M. Unknown
Week Eleven SOAP Note 3 P.G.F. Deceased of MI Past Surgery History (PSH): Appendectomy 2011 Personal/Social History: Tobacco Use: ½ pack daily x 5 years Smokeless Tobacco: NONE Passive Smoke: Daily Drug Use: NONE HIV risk: Patient admits that she does occasionally have sex with people that she 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: Always Sun Exposure: Frequently in summer Current Medications: Ibuprofen 400mg for occasionally for menstrual cramps or headache NuvaRing for contraception Review 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.

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