CONPH NSG6330/NSG6430 SOAP Notes Week 2 Subjective,
Objective, Assessment, Plan 2025-2026 Updates
CONPH NSG6330/NSG6430 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Wisline Dorvil Course: NSG 6430
Patient Name: (Initials ONLY) J.C Date: 3/28/2025 Time: 2:00 PM
Ethnicity: Hispanic Age: 64 Sex: F
SUBJECTIVE
CC: The patient presents with vaginal bleeding post-menopause.
HPI: A 64-year-old female with a past medical history of diabetes, hypertension, hypothyroidism, and hyperlipidemia.
She reports experiencing vaginal bleeding after menopause, which she describes as light and intermittent. No
associated pain or pelvic discomfort noted. Denies any other significant symptoms such as fever, weight loss, or
changes in bowel habits
Medications:
Previous Medical History: Diabetes mellitus type 2 Hypertension, hyperthyroidism, and hyperlipidemia Allergies:No
know allergies
Medication Intolerances: No medication intolerances
Chronic Illnesses/Major traumas: none
Hospitalizations/Surgeries: none
FAMILY HISTORY
M:
MGM:
MGF:
F:
PGM:
PGF:
Social History: Denies smoking or any tobacco use, occasional social drinker, about 1-2 drinks per week, denies use of
recreational drugs, lives with her spouse; independent in activities of daily living, occasionally walks, but no regular
exercise routine, Eat Generally healthy diet with a focus on managing diabetes and hyperlipidemia.
REVIEW OF SYSTEMS
General:The patient appears well groomed, well nourish, Cardiovascular: No chest pain, palpitations, or swelling
no sign of distress. Complaint about postmenopausal
vaginal bleeding with discomfort
Skin: Respiratory:No shortness of breath, cough, or wheezing.
Eyes:denies pian, discharge, itching, watery, or burning, Gastrointestinal:Bowel movements regular, last BM was
blurred vision this morning. No abdominal pain or changes in bowel
habits.
Ears: Patients deny ear pain or discharge. She denies a Genitourinary/Gynecological:Vaginal bleeding
history of ear infections. Denies hearing loss. postmenopause: no dysuria, hematuria, or increased
urinary frequency.
Nose/Mouth/Throat: Musculoskeletal:No joint pain or swelling
Objective, Assessment, Plan 2025-2026 Updates
CONPH NSG6330/NSG6430 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Wisline Dorvil Course: NSG 6430
Patient Name: (Initials ONLY) J.C Date: 3/28/2025 Time: 2:00 PM
Ethnicity: Hispanic Age: 64 Sex: F
SUBJECTIVE
CC: The patient presents with vaginal bleeding post-menopause.
HPI: A 64-year-old female with a past medical history of diabetes, hypertension, hypothyroidism, and hyperlipidemia.
She reports experiencing vaginal bleeding after menopause, which she describes as light and intermittent. No
associated pain or pelvic discomfort noted. Denies any other significant symptoms such as fever, weight loss, or
changes in bowel habits
Medications:
Previous Medical History: Diabetes mellitus type 2 Hypertension, hyperthyroidism, and hyperlipidemia Allergies:No
know allergies
Medication Intolerances: No medication intolerances
Chronic Illnesses/Major traumas: none
Hospitalizations/Surgeries: none
FAMILY HISTORY
M:
MGM:
MGF:
F:
PGM:
PGF:
Social History: Denies smoking or any tobacco use, occasional social drinker, about 1-2 drinks per week, denies use of
recreational drugs, lives with her spouse; independent in activities of daily living, occasionally walks, but no regular
exercise routine, Eat Generally healthy diet with a focus on managing diabetes and hyperlipidemia.
REVIEW OF SYSTEMS
General:The patient appears well groomed, well nourish, Cardiovascular: No chest pain, palpitations, or swelling
no sign of distress. Complaint about postmenopausal
vaginal bleeding with discomfort
Skin: Respiratory:No shortness of breath, cough, or wheezing.
Eyes:denies pian, discharge, itching, watery, or burning, Gastrointestinal:Bowel movements regular, last BM was
blurred vision this morning. No abdominal pain or changes in bowel
habits.
Ears: Patients deny ear pain or discharge. She denies a Genitourinary/Gynecological:Vaginal bleeding
history of ear infections. Denies hearing loss. postmenopause: no dysuria, hematuria, or increased
urinary frequency.
Nose/Mouth/Throat: Musculoskeletal:No joint pain or swelling
