SOAP NOTE
Student Name: Course: NSG6430
Name: S.D. Date: 02/15/2024 Time: 1546
Ethnicity: African American Age: 62 Sex: F
SUBJECTIVE
CC: “I broke out with a rash on my vagina, they look like little bumps”
HPI: A 62-year-old African American female who presents with a chief complaint of a rash
on her vagina. She reports that the rash began approximately one week ago and has
progressively worsened. The patient describes the rash as painful and associated with a
burning sensation. She notes the presence of fluid-filled blisters on the affected area.
Additionally, the patient reports experiencing moderate itching and discomfort. There is no
reported history of recent sexual activity or new topical products.
Medications: (list with reason for med )
Amlodipine 5mg daily, Simvastatin 20mg daily
PMH
Allergies: PCN- unknown
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension, hyperlipidemia, GERD
Hospitalizations/Surgeries- Appendectomy, tubal ligation
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:06:52 GMT -05:00
https://www.coursehero.com/file/235913063/NSG6430-Week-1-SOAP-Costa-Cdocx/
, Family History
M: Alive- CVA, Hypertension, Diabetes
F: Deceased MI
Social History
The patient reports a recent divorce, separated from her spouse of 25 years for the past three
years. She has three adult children residing out of state. The patient denies recent sexual
activity but states she slept with someone new 6 months ago. She also denies substance
abuse, alcohol consumption, or tobacco use.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of breath,
Skin Respiratory
No rash, lesions, or other skin abnormalities Denies dyspnea denies cough.
Eyes Gastrointestinal
Denies any visual changes Denies abdominal pain, nausea, vomiting or
diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Reports painful pustules on labia, denies
dysuria and frequency
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:06:52 GMT -05:00
https://www.coursehero.com/file/235913063/NSG6430-Week-1-SOAP-Costa-Cdocx/
Student Name: Course: NSG6430
Name: S.D. Date: 02/15/2024 Time: 1546
Ethnicity: African American Age: 62 Sex: F
SUBJECTIVE
CC: “I broke out with a rash on my vagina, they look like little bumps”
HPI: A 62-year-old African American female who presents with a chief complaint of a rash
on her vagina. She reports that the rash began approximately one week ago and has
progressively worsened. The patient describes the rash as painful and associated with a
burning sensation. She notes the presence of fluid-filled blisters on the affected area.
Additionally, the patient reports experiencing moderate itching and discomfort. There is no
reported history of recent sexual activity or new topical products.
Medications: (list with reason for med )
Amlodipine 5mg daily, Simvastatin 20mg daily
PMH
Allergies: PCN- unknown
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension, hyperlipidemia, GERD
Hospitalizations/Surgeries- Appendectomy, tubal ligation
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:06:52 GMT -05:00
https://www.coursehero.com/file/235913063/NSG6430-Week-1-SOAP-Costa-Cdocx/
, Family History
M: Alive- CVA, Hypertension, Diabetes
F: Deceased MI
Social History
The patient reports a recent divorce, separated from her spouse of 25 years for the past three
years. She has three adult children residing out of state. The patient denies recent sexual
activity but states she slept with someone new 6 months ago. She also denies substance
abuse, alcohol consumption, or tobacco use.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of breath,
Skin Respiratory
No rash, lesions, or other skin abnormalities Denies dyspnea denies cough.
Eyes Gastrointestinal
Denies any visual changes Denies abdominal pain, nausea, vomiting or
diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Reports painful pustules on labia, denies
dysuria and frequency
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:06:52 GMT -05:00
https://www.coursehero.com/file/235913063/NSG6430-Week-1-SOAP-Costa-Cdocx/
