Stacy Martin
NSG 6430
Week 7 SOAP Note
November 6, 2019
Professor Dr. Zella Peters
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, SOAP NOTE
Name: QH Date: 11/6/19 Time: 0830
Age: 27 Sex: Female
SUBJECTIVE
CC: “I an passing blood clots.”
HPI: QH is a 27 year-old-female who presents with irregular bleeding that is heavier than her
norm. She reports passing dark colored blood clots. She has associated abdominal pain, cramps
and low back pain. She is bisexual and has not been sexually active with men in 3+ months and
she is on birth control. She is in a monogamous relationship. Her bleeding started 3 weeks ago.
The first week was irregular and she continued to bleed where she got heavier bleeding on the
third week. No history of abnormal pap.
Medications:
Sprintec 28 1 tablet PO daily for birth control
Naproxen 500 mg Q12 for pain PRN pain
Iron OTC unknown mg daily
PMH: Nulliparous
Allergies,: none
Medication Intolerances: No known medication intolerances
Chronic Illnesses/Major traumas: No major traumas. History of Anemia, Migraines,
Menstrual cramps and irregular menses.
Hospitalizations/Surgeries: none
Family History: mother-none
Father- unknown
Social History: Denies smoking, Occasional ETOH and denies any illicit substances
ROS
General: Pleasant, Black female who Cardiovascular: Denies chest pain, palpitation,
This study source was downloaded by 100000851720696 from CourseHero.com on 06-21-2024 18:49:26 GMT -05:00
https://www.coursehero.com/file/51641572/6430-Week7SoapNotedocx/
NSG 6430
Week 7 SOAP Note
November 6, 2019
Professor Dr. Zella Peters
This study source was downloaded by 100000851720696 from CourseHero.com on 06-21-2024 18:49:26 GMT -05:00
https://www.coursehero.com/file/51641572/6430-Week7SoapNotedocx/
, SOAP NOTE
Name: QH Date: 11/6/19 Time: 0830
Age: 27 Sex: Female
SUBJECTIVE
CC: “I an passing blood clots.”
HPI: QH is a 27 year-old-female who presents with irregular bleeding that is heavier than her
norm. She reports passing dark colored blood clots. She has associated abdominal pain, cramps
and low back pain. She is bisexual and has not been sexually active with men in 3+ months and
she is on birth control. She is in a monogamous relationship. Her bleeding started 3 weeks ago.
The first week was irregular and she continued to bleed where she got heavier bleeding on the
third week. No history of abnormal pap.
Medications:
Sprintec 28 1 tablet PO daily for birth control
Naproxen 500 mg Q12 for pain PRN pain
Iron OTC unknown mg daily
PMH: Nulliparous
Allergies,: none
Medication Intolerances: No known medication intolerances
Chronic Illnesses/Major traumas: No major traumas. History of Anemia, Migraines,
Menstrual cramps and irregular menses.
Hospitalizations/Surgeries: none
Family History: mother-none
Father- unknown
Social History: Denies smoking, Occasional ETOH and denies any illicit substances
ROS
General: Pleasant, Black female who Cardiovascular: Denies chest pain, palpitation,
This study source was downloaded by 100000851720696 from CourseHero.com on 06-21-2024 18:49:26 GMT -05:00
https://www.coursehero.com/file/51641572/6430-Week7SoapNotedocx/
