CONPH NSG6330/NSG6430 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Lorie Sullivan Course: NSG6430
Patient Name: (Initials ONLY) L.C. Date: 2/22/2024 Time: 1624
Ethnicity: Hispanic Age: 36 Sex: Female
SUBJECTIVE
CC: Abnormal vaginal bleeding with positive pregnancy test
HPI: 36 year old hispanic female presents to clinic for a positive home pregnancy test on 1/9/24. She reports she has
been “bleeding for 10 days and things she had a spontaneous abortion.” She is requesting Depo Provera if she is not
pregnant. GPAL: G3, T3, P0, A0, L3. Last pap 2023- Dr Grant or Dr Gnam (She is not sure). EDC 10/16/24 based on
LMP of 1/9/24. Age of menarche 15.
Medications: Prenatal 27-1 mg 1 tablet by mouth once daily for pregnancy.
Previous Medical History: malaise and fatigue, esophageal reflux disease
Allergies: NKDA
Medication Intolerances:None
Chronic Illnesses/Major traumas: none
Hospitalizations/Surgeries: Child birth
FAMILY HISTORY
M: osteoporosis, essential hypertension
MGM: breast cancer
MGF: alzheimer
F:hypertension
PGM:malignant neoplasms unspecified site
PGF: Stomach cancer, heart disease, malignant neoplasm of prostate
Social History:Denies smoking, alcohol, mariuana or illicit drug use.
REVIEW OF SYSTEMS
General:Denies fever, chills, sweats or weight changes Cardiovascular: denies chest pain, days-near, orthopneia
or palpitations
Skin:denies rash, bruises or other lesions Respiratory: denies cough, sputum production, sob or
wheezing
Eyes: denies rashes, bruises or other lesions Gastrointestinal: denies abdominal pain, nausea, vomiting,
diarrhea or constipation
Ears:denies ear pain, ringing in ears or drainage Genitourinary/Gynecological: denies dyslexia, frequency or
hematuria, Vaginal bleeding
Nose/Mouth/Throat: denies sore throat, or swollen glands Musculoskeletal: denies muscle aches or joint pains
Breast: denies breast tenderness, dimpling, or nipple Neurological: denies weakness, headaches, tremors or gait
discharge abnormalities
Heme/Lymph/Endo: denies bleeding problems, or swollen Psychiatric: denies anxiety or depression
glands
OBJECTIVE
Weight: 195 Height: 68 BMI:29.65 BP:141/87 Temp: 98.3 Pulse: 80 Resp:18
General Appearance: Alert and oriented x 3, no distress, cooperative with exam
Skin: Warm, dry, turgor good, no abnormal lesions or rashes
HEENT: Eyes- denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and
dry eyes. Patient states she does wear contacts. Ears, nose, mouth, and throat- Patient denies vertigo, headaches,
sinus problems, epistaxis, hoarseness, dental problems, oral lesions, hearing loss or changes, nasal congestion.
Cardiovascular: RRR, no murmur
10162023 Page 1 of 2
Student Name: Lorie Sullivan Course: NSG6430
Patient Name: (Initials ONLY) L.C. Date: 2/22/2024 Time: 1624
Ethnicity: Hispanic Age: 36 Sex: Female
SUBJECTIVE
CC: Abnormal vaginal bleeding with positive pregnancy test
HPI: 36 year old hispanic female presents to clinic for a positive home pregnancy test on 1/9/24. She reports she has
been “bleeding for 10 days and things she had a spontaneous abortion.” She is requesting Depo Provera if she is not
pregnant. GPAL: G3, T3, P0, A0, L3. Last pap 2023- Dr Grant or Dr Gnam (She is not sure). EDC 10/16/24 based on
LMP of 1/9/24. Age of menarche 15.
Medications: Prenatal 27-1 mg 1 tablet by mouth once daily for pregnancy.
Previous Medical History: malaise and fatigue, esophageal reflux disease
Allergies: NKDA
Medication Intolerances:None
Chronic Illnesses/Major traumas: none
Hospitalizations/Surgeries: Child birth
FAMILY HISTORY
M: osteoporosis, essential hypertension
MGM: breast cancer
MGF: alzheimer
F:hypertension
PGM:malignant neoplasms unspecified site
PGF: Stomach cancer, heart disease, malignant neoplasm of prostate
Social History:Denies smoking, alcohol, mariuana or illicit drug use.
REVIEW OF SYSTEMS
General:Denies fever, chills, sweats or weight changes Cardiovascular: denies chest pain, days-near, orthopneia
or palpitations
Skin:denies rash, bruises or other lesions Respiratory: denies cough, sputum production, sob or
wheezing
Eyes: denies rashes, bruises or other lesions Gastrointestinal: denies abdominal pain, nausea, vomiting,
diarrhea or constipation
Ears:denies ear pain, ringing in ears or drainage Genitourinary/Gynecological: denies dyslexia, frequency or
hematuria, Vaginal bleeding
Nose/Mouth/Throat: denies sore throat, or swollen glands Musculoskeletal: denies muscle aches or joint pains
Breast: denies breast tenderness, dimpling, or nipple Neurological: denies weakness, headaches, tremors or gait
discharge abnormalities
Heme/Lymph/Endo: denies bleeding problems, or swollen Psychiatric: denies anxiety or depression
glands
OBJECTIVE
Weight: 195 Height: 68 BMI:29.65 BP:141/87 Temp: 98.3 Pulse: 80 Resp:18
General Appearance: Alert and oriented x 3, no distress, cooperative with exam
Skin: Warm, dry, turgor good, no abnormal lesions or rashes
HEENT: Eyes- denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and
dry eyes. Patient states she does wear contacts. Ears, nose, mouth, and throat- Patient denies vertigo, headaches,
sinus problems, epistaxis, hoarseness, dental problems, oral lesions, hearing loss or changes, nasal congestion.
Cardiovascular: RRR, no murmur
10162023 Page 1 of 2
