WH SOAP Note 8

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School

Capella University *

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631

Subject

Health Science

Date

Apr 3, 2024

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docx

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4

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SOAP Note 8______ NU631________ Herzing University Name:_Scarlin Rhoades________________________ Typhon Encounter #: 4316-20240318- 002 _____________________ Comprehensive:_x___Focused:____ S: SUBJECTIVE DATA CC: “I feel something protruding from my private part” HPI: Patient is a 61-year-old female presenting today with complaints of vaginal discomfort and the sensation of a piece of tissue hanging out of her vagina. She sates she felt it 3 days ago and it rubs against her clothing. She denies any bleeding, discharge, urine problems, fever, or pain. She denies being sexually active for many years. PMH: HTN ALLERGIES None MEDICATIONS Amlodipine 10 mg, once daily SH She is retired, and lives with her son, his wife and 2 grandchildren Denies smoking, alcohol, or drug use Drinks caffeine daily FH Both parents are deceased 3 adult children healthy Denies history of cancer HEALTH PROMOTION & MAINTENANC E Pap smear- today Mammogram- 6/2024 DEXA scan- never She does not drive, but wears a seatbelt when in the passenger seat Eye exam- years ago Dental exam- years ago Does not see a dermatologist and rarely wear sunscreen. She has her covid and flu vaccines up to date, does not remember if ever had shingles, pneumococcal, RSV vaccines ROS (put N/A in sections not completed day of exam) Constitutional Denies fever, pain Head n/a Eyes n/a Ears, Nose, Mouth, Throat n/a Neck n/a Cardiovascular/Peripheral Vascular n/a Respiratory n/a Breast n/a
SOAP Note 8______ NU631________ Herzing University Name:_Scarlin Rhoades________________________ Typhon Encounter #: 4316-20240318- 002 _____________________ Comprehensive:_x___Focused:____ Gastrointestinal Denies abdominal pain, constipation or diarrhea Genitourinary Denies dysuria, frequency, discharge Musculoskeletal n/a Integumentary Denies rash Neurological n/a Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) n/a Endocrine n/a Hematologic/Lymphatic n/a Allergic/Immunologic n/a Other O: OBJECTIVE DATA VITALS: HR: 87 RR: 16 BP: 126/84 Temp: 97.6 SpO2%: - Ht: - Wt: 134 lb BMI: - Age: 61 LMP: unknown PAIN: 0/10 PHYSICAL EXAM (Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) General Appearance Appears uncomfortable, calmed and pleasant Head n/a Eyes n/a ENT, Mouth n/a Neck n/a Cardiovascular/Peripheral Vascular n/a Respiratory n/a Breast n/a Gastrointestinal Abdomen soft, non-tender Genitourinary Male External Exam n/a Internal Exam n/a Genitourinary Female External Exam Appropriate hair distribution, no lumps or masses, 1 vesicular lesion on the left labia majora Internal Exam Cervix pink and moist, os extended to the 8 o’clock region, with deformity related to birth trauma
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