CONPH NSG6330/NSG6430 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Lorie Sullivan Course: NSG6430
Patient Name: (Initials ONLY) V.B. Date: 2/15/2023 Time: 0432 pm
Ethnicity: Black Age: 32 Sex: Female
SUBJECTIVE
CC: vaginal bleeding. Seen at Lackey ER last night and was referred to clinic
HPI: 32 year old black female was referred by Lackey ER for heavy bleeding that started yesterday. Patient went to
Local ER and was told to come here. She states she “thinks a cyst ruptured.” She is a poor historian. Medical records
were recorded from ER visit. She did have radiology studies done at ER. She states she had a copper IUD placed 2-3
years ago. She is G4, P4, P0, A0, L4. Reports 3 normal vaginal deliveries and 1 cesarean section. She reports her last
pap was done in Arkansas and that it was normal. She denies abdominal pain or dizziness. She states she is soaking
one large pad every 4 hours. She is not sexually active. Last pap was done in Arkansas 2 years ago.
Medications:Melatonin 10 mg 1 tablet by mouth at bedtime for insomnia
Previous Medical History: Insomnia, Ovarian cyst
Allergies: No know drug allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas: insomnia
Hospitalizations/Surgeries: cesarean
FAMILY HISTORY
M: Deceased heart attack
MGM:
MGF:
F: alive. Hypertension
PGM:
PGF:
Social History: Denies smoking, alcohol, marijuana or illicit drug use.
REVIEW OF SYSTEMS
General: Denies fever, bills, sweats or weight changes Cardiovascular: Denies chest pain, dyspnea, orthopedic
or palpitations
Skin: Denies rash, bruises or other lesions Respiratory: Denies cough, sputum production, shortnes
of breath or wheezing
Eyes: Denies blurred vision Gastrointestinal: Denies abdominal pain, nausea,
vomiting, diarrhea or constipation
Ears: Denies ear pain, ringing of rears or drainage Genitourinary/Gynecological: Denies dysuria, frequency o
hematuria, vaginal bleeding
Nose/Mouth/Throat: Denies sore throat or swollen glands Musculoskeletal: Denies muscle aches or pains
Breast: Denies breast tenderness, dimpling or nipple Neurological: Denies weakness, headaches, tremors or
discharge gait abnormalities
Heme/Lymph/Endo: Denies bleeding problems or swollen Psychiatric: Denies anxiety or depression
glands
OBJECTIVE
Weight: 157lb Height: 64 in BMI: 26.95 BP:120/76 Temp: 98.3 Pulse: 72 Resp: 18
10162023 Page 1 of 2
Student Name: Lorie Sullivan Course: NSG6430
Patient Name: (Initials ONLY) V.B. Date: 2/15/2023 Time: 0432 pm
Ethnicity: Black Age: 32 Sex: Female
SUBJECTIVE
CC: vaginal bleeding. Seen at Lackey ER last night and was referred to clinic
HPI: 32 year old black female was referred by Lackey ER for heavy bleeding that started yesterday. Patient went to
Local ER and was told to come here. She states she “thinks a cyst ruptured.” She is a poor historian. Medical records
were recorded from ER visit. She did have radiology studies done at ER. She states she had a copper IUD placed 2-3
years ago. She is G4, P4, P0, A0, L4. Reports 3 normal vaginal deliveries and 1 cesarean section. She reports her last
pap was done in Arkansas and that it was normal. She denies abdominal pain or dizziness. She states she is soaking
one large pad every 4 hours. She is not sexually active. Last pap was done in Arkansas 2 years ago.
Medications:Melatonin 10 mg 1 tablet by mouth at bedtime for insomnia
Previous Medical History: Insomnia, Ovarian cyst
Allergies: No know drug allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas: insomnia
Hospitalizations/Surgeries: cesarean
FAMILY HISTORY
M: Deceased heart attack
MGM:
MGF:
F: alive. Hypertension
PGM:
PGF:
Social History: Denies smoking, alcohol, marijuana or illicit drug use.
REVIEW OF SYSTEMS
General: Denies fever, bills, sweats or weight changes Cardiovascular: Denies chest pain, dyspnea, orthopedic
or palpitations
Skin: Denies rash, bruises or other lesions Respiratory: Denies cough, sputum production, shortnes
of breath or wheezing
Eyes: Denies blurred vision Gastrointestinal: Denies abdominal pain, nausea,
vomiting, diarrhea or constipation
Ears: Denies ear pain, ringing of rears or drainage Genitourinary/Gynecological: Denies dysuria, frequency o
hematuria, vaginal bleeding
Nose/Mouth/Throat: Denies sore throat or swollen glands Musculoskeletal: Denies muscle aches or pains
Breast: Denies breast tenderness, dimpling or nipple Neurological: Denies weakness, headaches, tremors or
discharge gait abnormalities
Heme/Lymph/Endo: Denies bleeding problems or swollen Psychiatric: Denies anxiety or depression
glands
OBJECTIVE
Weight: 157lb Height: 64 in BMI: 26.95 BP:120/76 Temp: 98.3 Pulse: 72 Resp: 18
10162023 Page 1 of 2
