NSG6420 Week 9 SOAP
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School
South University, Savannah *
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Course
6420
Subject
Chemistry
Date
Feb 20, 2024
Type
docx
Pages
6
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SOAP NOTE
Student Name:
Course: NSG6420
Name:
Date:
02/01/2024
Time: 1545
Ethnicity:
Hispanic
Age:
32
Sex:
F
SUBJECTIVE
CC: “I have been having white cottage like vaginal discharge and itching”
HPI: A 32-year-old Hispanic female, presents with a chief complaint of white cottage-like vaginal discharge and itching persisting for the past week. She describes the discharge as a novel occurrence and notes no associated foul odor. The patient reports a regular menstrual history, denies recent changes in hygiene or sexual activity, and is in a monogamous relationship. She has not used any vaginal products or medications and has no history of sexually transmitted infections or recent antibiotic use. Seeking relief from the discomfort, she has not attempted self-treatment and hopes for a thorough evaluation to determine the cause. Medications: (list with reason for med )
Albuterol Inhaler 90mcg PRN PMH
Allergies: NSAIDS- Shortness of breath
Medication Intolerances:
None
Chronic Illnesses/Major traumas: Asthma Hospitalizations/Surgeries- N/A Family History
M: Alive- pre-diabetes
MGM: Alive- unknown
MGF: Alive unknown
F: Alive- hypertension
PGM: Alive- unknown PGF
deceased- unknown
Social History
Patient reports being in a monogamous relationship with her husband and does not engage in
high-risk sexual behaviors. Ms. Rodriguez resides in a suburban setting and is employed in a
clerical position. She denies usage of drugs, alcohol, or nicotine.
ROS
General Patient denies night sweats, fatigue or weakness
Cardiovascular
Denies any chest pain or shortness of breath, Skin
No rash, lesions, or other skin abnormalities
Respiratory
Denies dyspnea denies cough.
Eyes
Denies any visual changes
Gastrointestinal
Denies abdominal pain, nausea, vomiting or diarrhea
Ears
Denies ear pain or hearing loss
Genitourinary/Gynecological
Reports white discharge and irritation
Nose/Mouth/Throat
Denies loss of smell, sore throat, nasal discharge, and congestion Musculoskeletal
Denies pain
Breast
Denies pain or discomfort Neurological
Denies syncope, seizures, headache, or dizziness Heme/Lymph/Endo
Denies bleeding, no enlarged lymph nodes Psychiatric
Denies depression, anxiety, SI or sleeping difficulty OBJECTIVE
Weight 66g BMI
23.37
Temp
37.1
BP
107/80
Height 5’6
Pulse
77
Resp
16
General Appearance
The patient appears well-groomed and in no apparent distress, demonstrating a calm demeanor and cooperative attitude during the encounter.
Skin
Skin in clean, dry and intact. HEENT
Head is normocephalic, atraumatic. Eyes: Pupils are equal, round, and reactive to light, vision grossly normal. Ears: Canals patent. Bilateral tympanic membranes clear, landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Tenderness present on palpation at the sinus maxillary and frontal sinus
Neck: Supple. Full ROM; trachea midline. Mouth/throat: Oral mucosa is moist and pink. Teeth are in good repair
.
Pharynx appears pink without any erythema or exudate. The uvula is midline. The tonsils are without enlargement or evidence of inflammation.
Cardiovascular
Normal rhythm and rate, characterized by clearly audible S1 and S2 heart sounds. No additional auscultatory findings, including murmurs, rubs, or clicks, are noted. Absence of edema is observed, and pulses are uniformly assessed as 3+. Capillary refill time is measured at a brisk two seconds.
Respiratory
Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal
Gastrointestinal
Abdomen is symmetrical and slim, soft, non-tender, no guarding or rebound tenderness, bowel sounds present in all four quadrants
Breast
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