SU_NSG6430_WK_Soap_WK8.docx - SOAP NOTE Name Y.D Date Time Age 21 Sex Female SUBJECTIVE CC \u201cVaginal lesion\u201d HPI Y.D 21-year-old Hispanic female

SU_NSG6430_WK_Soap_WK8.docx - SOAP NOTE Name Y.D Date Time...

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SOAP NOTEName:Y.D.Date:10/31/2019Time: Age: 21Sex:FemaleSUBJECTIVECC: “Vaginal lesion”HPI: Y.D. 21-year-old Hispanic female presents to clinic for vaginal lesions that have been present for about a month. The lesions are located at the vaginal opening. No pain present with the lesions. No history of this type of issue or similar in the past. No sure whether partners have similar issues. Admits to having multiplepartners and not consistently using condoms. Denies complaints of fevers, chills, vaginal itching dyspareunia, pain during urination, or urinary urgency/ frequency. Medications: Oral contraception (not sure of the name)PMH G:0, T:0, P:0, A:0, L:0Allergies: NKDAMedication Intolerances: N/AChronic Illnesses/Major traumas: N/A1
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Hospitalizations/Surgeries (include delivery of pregnancies here):G:0, T:0, P:0, A:0, L:0Family HistoryFather: 48 y.o. AL&W Mother: 45 y.o. AL&WBrother: 24 y.o. AL&WSister: 17 y.o. AL&WSocial HistoryCurrently works part-time at Starbucks and fulltime student at Loyola University. Lives in off campus apartment with 2 roommates. Currently in last year of college. Currently have 2 sexual partners and admitsto not using condoms consistently. Does not smoke tobacco but does admits to smoking marijuana a coupleof times. Drinks a few beers with friends a couple of times a week but has never gotten wasted. ROS (if you are seeing a patient for an Episodic OV – you may alter the ROS accordingly)General Denies unintentional weight gain, loss, fatigue, changes in eating habits, fever, chills, night sweats, or change in energy levelCardiovascularDenies complaints of chest pain, palpitations, PND,orthopnea, edemaSkinDenies problems with delayed wound healing,
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