NSG6430 Week 3 SOAP CHAVIS

CONPH NSG6330/NSG6430 Subjective, Objective, Assessment, Plan (SOAP) Notes Student Name: Rebecca Chavis Course: NSG 6430 Patient Name: (Initials ONLY) MS Date: 08/29/2023 Time: 1500  Ethnicity: White Age: 21 Sex: Female SUBJECTIVE CC:  I need a refill on my birth control pills. HPI:  Patient presents to the clinic for refill on her birth control pills. Patient states that she has started taking her last pack. Medications: Ortho Tri-Cyclen one tab ny mouth daily. Previous Medical History: None Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: None FAMILY HISTORY M: GERD MGM: Hypertension, Diabetes Type III MGF: Unknown F: None PGM: Arthritis PGF: MII Social History: Patient denies smoking, but states she drinks about 6 mixed drinks on the weekends when she goes out with her friends. Patient denies any drug usage. REVIEW OF SYSTEMS General: Denies chills, fevers, night sweats, or changes in weight Cardiovascular: Denies chest pain, palpitations Skin: Denies sores or lesions Respiratory: Denies SOB or cough Eyes: Denies dry eyes and irritation, or visual changes Gastrointestinal: Denies constipation, nausea, vomiting, or diarrhea Ears: Denies pain or hearing changes Genitourinary/Gynecological: Denies pain with urination, denies vaginal discharge Nose/Mouth/Throat: Deferred Musculoskeletal: deferred Breast: Deferred Neurological: Denies headaches, lightheadedness, or dizziness Heme/Lymph/Endo: Denies swollen glands or bruising Psychiatric: Denies anxiety, depression, or suicidal thoughts OBJECTIVE Weight:  63in Height: 148.6lbs BMI: 26.3 BP: 118/72 Temp : 98.1f Pulse: 84 Resp: 18 General Appearance: Well-developed, healthy appearing female Skin: Skin is clear, no sores or lesions noted. HEENT: Deferred Cardiovascular: S1, S2 noted with regular rate and rhythm, no murmurs noted. 03302023 Page 1 of 2