SOAP NOTE
Student Name: Course: NSG6430
Name: K.C. Date: 3/23/2024 Time: 1100
Ethnicity: White Age: 37 Sex: F
SUBJECTIVE
CC: “I have been having lower abdominal pain for 2 days”
HPI: The patient, a 37-year-old Caucasian female, presents with complaints of left lower
abdominal pain persisting for the last two days. The pain is described as dull and constant,
rated 6 out of 10 on the pain scale. She denies any recent trauma, but notes exacerbation of
discomfort with movement. There are no associated symptoms such as nausea, vomiting,
fever, or changes in bowel habits reported. She states she has a history of irregular menstrual
cycles but denies any prior occurrences of similar pain.
Medications: (list with reason for med )
N/A
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Denies
Hospitalizations/Surgeries- Denies
Family History
M: Alive- 60 years old- htn
MGM: Alive 84 years old dementia
MGF: Deceased
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:02:41 GMT -05:00
https://www.coursehero.com/file/235913064/NSG6430-Week-6-SOAP-Costa-Cdocx/
, F: Alive 59 years old Htn, hyperlipidemia, Diabetes mellitus type 2
PGM: 89- alive
PGF deceased
Social History
The patient reports being a non-smoker and denies alcohol or illicit drug use. She works full-
time as a software engineer and lives with her spouse and two children.
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 or cough
Eyes Gastrointestinal
Deferred Complains of lower abdominal pain, denies n/v/d
Ears Genitourinary/Gynecological
Deferred Reports irregular menstrual cycles, can range up
to 45 days, and occasionally skips a month.
Denies history of severe menstrual cramps or
abnormal bleeding
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:02:41 GMT -05:00
https://www.coursehero.com/file/235913064/NSG6430-Week-6-SOAP-Costa-Cdocx/
Student Name: Course: NSG6430
Name: K.C. Date: 3/23/2024 Time: 1100
Ethnicity: White Age: 37 Sex: F
SUBJECTIVE
CC: “I have been having lower abdominal pain for 2 days”
HPI: The patient, a 37-year-old Caucasian female, presents with complaints of left lower
abdominal pain persisting for the last two days. The pain is described as dull and constant,
rated 6 out of 10 on the pain scale. She denies any recent trauma, but notes exacerbation of
discomfort with movement. There are no associated symptoms such as nausea, vomiting,
fever, or changes in bowel habits reported. She states she has a history of irregular menstrual
cycles but denies any prior occurrences of similar pain.
Medications: (list with reason for med )
N/A
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Denies
Hospitalizations/Surgeries- Denies
Family History
M: Alive- 60 years old- htn
MGM: Alive 84 years old dementia
MGF: Deceased
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:02:41 GMT -05:00
https://www.coursehero.com/file/235913064/NSG6430-Week-6-SOAP-Costa-Cdocx/
, F: Alive 59 years old Htn, hyperlipidemia, Diabetes mellitus type 2
PGM: 89- alive
PGF deceased
Social History
The patient reports being a non-smoker and denies alcohol or illicit drug use. She works full-
time as a software engineer and lives with her spouse and two children.
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 or cough
Eyes Gastrointestinal
Deferred Complains of lower abdominal pain, denies n/v/d
Ears Genitourinary/Gynecological
Deferred Reports irregular menstrual cycles, can range up
to 45 days, and occasionally skips a month.
Denies history of severe menstrual cramps or
abnormal bleeding
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:02:41 GMT -05:00
https://www.coursehero.com/file/235913064/NSG6430-Week-6-SOAP-Costa-Cdocx/
