WH SOAP Note 8
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School
Capella University *
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Course
631
Subject
Health Science
Date
Apr 3, 2024
Type
docx
Pages
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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