PRAC 6552: Advanced Nurse Practice in Reproductive Health Care
Week 7 GYNECOLOGIC HEALTH
Perveen Mistry
MSN-FNP, Walden University
PRAC 6552 Section 17, OB/GYN
Dr. Fonseca
April 12, 2024
© 2023 Walden University, LLC
This study source was downloaded by 100000901524459 from CourseHero.com on 12-11-2025 02:39:47 GMT -06:00
https://www.coursehero.com/file/238475996/WK7Assgn2-Mistry-Pdocx/
, PRAC 6552: Advanced Nurse Practice in Reproductive Health Care
Episodic/Focused SOAP Note Template
Patient Information:
K.P., 36, F, Caucasian
S.
CC (chief complaint): urge to urinate.
HPI: 36-year-old female presents for complaints of urge to urinate. Patient states she
has the urge to urinate but is unable to as of one day ago. Accompanying symptoms
include increase in frequency and burning discomfort when attempting. No relieving or
aggravating factors noted. No other complaints.
Current Medications: Synthroid 75 mcg, daily; Multivitamin women’s one a day, 1 pill
daily.
Allergies: Patient denies food allergies, medication allergies, and environmental
allergies.
PMHx: Immunizations UTD; last tetanus unknown; covid vaccination status not
applicable. She has a history of brainstem cancer at age 10 and underwent chemo
radiation for 1 year. Patient diagnosed with hypothyroidism at age 20.
Soc & Substance Hx: Patient works in customer service and has lived in Middlesex
throughout her life. She spends time with her friends and is very family oriented. She
does not have children and is the third oldest of 4. Patient denies history of tobacco use
and vaping. She drinks alcohol socially, approximately 1-2 drinks weekly of wine or
cocktail since age 21, and decaf coffee daily. Patient reports having a good home
environment with functioning smoke detectors. She does not text and drive and always
wears her seatbelt.
Fam Hx: Mother, age 59, diagnosed with PBC; father, age 61, no known medical
history; Parents are alive and well. 1 sister, age 37, no known medical history. 2
brothers, ages 39 and 34, no known medical history. Siblings alive and well.
Surgical Hx: No surgical history.
Mental Hx: Patient denies history of anxiety/depression. She denies SI/HI at this time.
Violence Hx: No apparent concerns of violence at home or work.
Reproductive Hx: Began menstruating at age 12; LMP 2/18/2024, periods are regular,
lasting 5 days. She has a 30-day cycle. She uses condoms for contraception. G0P0.
Patient is heterosexual. She is sexually active with 1 partner, long term boyfriend. She
© 2023 Walden University, LLC
This study source was downloaded by 100000901524459 from CourseHero.com on 12-11-2025 02:39:47 GMT -06:00
https://www.coursehero.com/file/238475996/WK7Assgn2-Mistry-Pdocx/
Week 7 GYNECOLOGIC HEALTH
Perveen Mistry
MSN-FNP, Walden University
PRAC 6552 Section 17, OB/GYN
Dr. Fonseca
April 12, 2024
© 2023 Walden University, LLC
This study source was downloaded by 100000901524459 from CourseHero.com on 12-11-2025 02:39:47 GMT -06:00
https://www.coursehero.com/file/238475996/WK7Assgn2-Mistry-Pdocx/
, PRAC 6552: Advanced Nurse Practice in Reproductive Health Care
Episodic/Focused SOAP Note Template
Patient Information:
K.P., 36, F, Caucasian
S.
CC (chief complaint): urge to urinate.
HPI: 36-year-old female presents for complaints of urge to urinate. Patient states she
has the urge to urinate but is unable to as of one day ago. Accompanying symptoms
include increase in frequency and burning discomfort when attempting. No relieving or
aggravating factors noted. No other complaints.
Current Medications: Synthroid 75 mcg, daily; Multivitamin women’s one a day, 1 pill
daily.
Allergies: Patient denies food allergies, medication allergies, and environmental
allergies.
PMHx: Immunizations UTD; last tetanus unknown; covid vaccination status not
applicable. She has a history of brainstem cancer at age 10 and underwent chemo
radiation for 1 year. Patient diagnosed with hypothyroidism at age 20.
Soc & Substance Hx: Patient works in customer service and has lived in Middlesex
throughout her life. She spends time with her friends and is very family oriented. She
does not have children and is the third oldest of 4. Patient denies history of tobacco use
and vaping. She drinks alcohol socially, approximately 1-2 drinks weekly of wine or
cocktail since age 21, and decaf coffee daily. Patient reports having a good home
environment with functioning smoke detectors. She does not text and drive and always
wears her seatbelt.
Fam Hx: Mother, age 59, diagnosed with PBC; father, age 61, no known medical
history; Parents are alive and well. 1 sister, age 37, no known medical history. 2
brothers, ages 39 and 34, no known medical history. Siblings alive and well.
Surgical Hx: No surgical history.
Mental Hx: Patient denies history of anxiety/depression. She denies SI/HI at this time.
Violence Hx: No apparent concerns of violence at home or work.
Reproductive Hx: Began menstruating at age 12; LMP 2/18/2024, periods are regular,
lasting 5 days. She has a 30-day cycle. She uses condoms for contraception. G0P0.
Patient is heterosexual. She is sexually active with 1 partner, long term boyfriend. She
© 2023 Walden University, LLC
This study source was downloaded by 100000901524459 from CourseHero.com on 12-11-2025 02:39:47 GMT -06:00
https://www.coursehero.com/file/238475996/WK7Assgn2-Mistry-Pdocx/
