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

Uploaded by BailiffCloverStork22

Report
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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