CONPH NSG6020 SOAP Notes Subjective, Objective, Assessment, Plan
Updated Study Solutions 2025-2026 Set
CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name:Wisline Dorvil Course: NSG6430
Patient Name: (Initials ONLY) R. R Date:4/3/2025 Time: 10. AM
Ethnicity: Two or more races. Age: 34 Sex: F
SUBJECTIVE (must complete this section)
CC: "I have been experiencing pelvic pain and vaginal discharge"
HPI: R. R is 34-year-old female who presents to the clinic with Pelvic pain and vaginal discharge. She indicates that the
pain started about a week ago then she discovered she was having vaginal discharge two days ago. The patient
describes the pain as moderate. She normally takes over-the-counter pain relievers whenever she experiences some
pain or headaches. However, when she realized the pelvic pain was accompanied by vaginal discharge, she did not
take any medication prior to the visit.
Medications:The patient indicates that she takes pain relievers whenever she has pain or headaches. However, since
she realized the pelvic pain was accompanied by vaginal discharge, she did not take any medications prior to the visit.
Previous Medical History: The patient has a previous history of chlamydia and gonorrhea.
Allergies:The patient does not report any allergies.
Medication Intolerances:Patient is not aware of any medical intolerances.
Chronic Illnesses/Major traumas: The patient does not have a history of traumas. She has a previous history of sexually
transmitted infections, chlamydia and gonorrhea.
Hospitalizations/Surgeries:The patient denies any history of surgeries or major hospitalizations.
FAMILY HISTORY (must complete this section)
M:Alive at 65 with a history of hypertension.
MGM: Deceased at 70 with no history of gynecological problems.
MGF: Deceased at 75 with no medical history on record.
F:Alive at 68 with a history of hypertension.
PGM:Alive at 80 and diabetic with no history of ovarian or cervical cancer or related conditions.
PGF:Deceased with no medical history on record.
Social History:The patient is a single mother of a 5-year daughter. She gave birth through normal delivery with no
complications. She works at a casino and restaurant in the city and is also studying for a nursing degree. She enrolls for
classes when she thinks the season is off-peak and is positive that she will complete and start her nursing career. She
is single and lives with her parents, who are now retired in their urban home. She is planning to move out when she
starts her career as a nurse. She drinks alcohol and has abused drugs especially when she is working in the casino
environment.
REVIEW OF SYSTEMS (must complete this section)
General:The patient appears to be a healthy and Cardiovascular: Denies chest pain, or palpitations.
wellnourished 34-year-old female. She does not present any Denies murmurs or activity intolerance.
signs of distress. She denies any recent changes in weight.
Skin: Patient has a smooth dry skin. She denies rashes, Respiratory: Patient denies cough. Denies shortness of
scaring or lesions on any part of the skin. She denies skin breath or dyspnea. Denies abnormal breathing effort.
itching or hair loss.
Updated Study Solutions 2025-2026 Set
CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name:Wisline Dorvil Course: NSG6430
Patient Name: (Initials ONLY) R. R Date:4/3/2025 Time: 10. AM
Ethnicity: Two or more races. Age: 34 Sex: F
SUBJECTIVE (must complete this section)
CC: "I have been experiencing pelvic pain and vaginal discharge"
HPI: R. R is 34-year-old female who presents to the clinic with Pelvic pain and vaginal discharge. She indicates that the
pain started about a week ago then she discovered she was having vaginal discharge two days ago. The patient
describes the pain as moderate. She normally takes over-the-counter pain relievers whenever she experiences some
pain or headaches. However, when she realized the pelvic pain was accompanied by vaginal discharge, she did not
take any medication prior to the visit.
Medications:The patient indicates that she takes pain relievers whenever she has pain or headaches. However, since
she realized the pelvic pain was accompanied by vaginal discharge, she did not take any medications prior to the visit.
Previous Medical History: The patient has a previous history of chlamydia and gonorrhea.
Allergies:The patient does not report any allergies.
Medication Intolerances:Patient is not aware of any medical intolerances.
Chronic Illnesses/Major traumas: The patient does not have a history of traumas. She has a previous history of sexually
transmitted infections, chlamydia and gonorrhea.
Hospitalizations/Surgeries:The patient denies any history of surgeries or major hospitalizations.
FAMILY HISTORY (must complete this section)
M:Alive at 65 with a history of hypertension.
MGM: Deceased at 70 with no history of gynecological problems.
MGF: Deceased at 75 with no medical history on record.
F:Alive at 68 with a history of hypertension.
PGM:Alive at 80 and diabetic with no history of ovarian or cervical cancer or related conditions.
PGF:Deceased with no medical history on record.
Social History:The patient is a single mother of a 5-year daughter. She gave birth through normal delivery with no
complications. She works at a casino and restaurant in the city and is also studying for a nursing degree. She enrolls for
classes when she thinks the season is off-peak and is positive that she will complete and start her nursing career. She
is single and lives with her parents, who are now retired in their urban home. She is planning to move out when she
starts her career as a nurse. She drinks alcohol and has abused drugs especially when she is working in the casino
environment.
REVIEW OF SYSTEMS (must complete this section)
General:The patient appears to be a healthy and Cardiovascular: Denies chest pain, or palpitations.
wellnourished 34-year-old female. She does not present any Denies murmurs or activity intolerance.
signs of distress. She denies any recent changes in weight.
Skin: Patient has a smooth dry skin. She denies rashes, Respiratory: Patient denies cough. Denies shortness of
scaring or lesions on any part of the skin. She denies skin breath or dyspnea. Denies abnormal breathing effort.
itching or hair loss.
