SOAP NOTE
Student Name: Course: NSG6430
Name: S.D. Date: 02/27/24 Time: 1430
Ethnicity: Hispanic Age: 18 Sex: F
SUBJECTIVE
CC: “I need a prescription for birth control.”
HPI: The patient is an 18-year-old Hispanic female presenting to discuss starting birth
control for the first time. She reports no previous use of any contraceptive methods. She
denies any current sexual activity but states she wants to be prepared and responsible.
Medications: (list with reason for med )
N/A
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: N/A
Hospitalizations/Surgeries- N/A
Family History
M: Alive- 39 years old
MGM: Alive 65 years old
MGF: Alive 71 years old
F: Alive 45 years old
PGM: Alive 81 years old
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:06:30 GMT -05:00
https://www.coursehero.com/file/235913062/NSG6430-Week-3-SOAP-Costa-Cdocx/
, PGF deceased
Social History
Patient denies smoking, use of recreational drugs, or any significant family history of
chronic diseases or genetic disorders. The patient is currently a college student and lives on
campus.
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
Denies any visual changes Denies abdominal pain, nausea, vomiting or
diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Reports menstrual cycles are regular, with a
typical cycle length of 28 days, and last for about
5 days with moderate flow. Denies history of
severe menstrual cramps or abnormal bleeding
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:06:30 GMT -05:00
https://www.coursehero.com/file/235913062/NSG6430-Week-3-SOAP-Costa-Cdocx/
Student Name: Course: NSG6430
Name: S.D. Date: 02/27/24 Time: 1430
Ethnicity: Hispanic Age: 18 Sex: F
SUBJECTIVE
CC: “I need a prescription for birth control.”
HPI: The patient is an 18-year-old Hispanic female presenting to discuss starting birth
control for the first time. She reports no previous use of any contraceptive methods. She
denies any current sexual activity but states she wants to be prepared and responsible.
Medications: (list with reason for med )
N/A
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: N/A
Hospitalizations/Surgeries- N/A
Family History
M: Alive- 39 years old
MGM: Alive 65 years old
MGF: Alive 71 years old
F: Alive 45 years old
PGM: Alive 81 years old
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:06:30 GMT -05:00
https://www.coursehero.com/file/235913062/NSG6430-Week-3-SOAP-Costa-Cdocx/
, PGF deceased
Social History
Patient denies smoking, use of recreational drugs, or any significant family history of
chronic diseases or genetic disorders. The patient is currently a college student and lives on
campus.
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
Denies any visual changes Denies abdominal pain, nausea, vomiting or
diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Reports menstrual cycles are regular, with a
typical cycle length of 28 days, and last for about
5 days with moderate flow. Denies history of
severe menstrual cramps or abnormal bleeding
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:06:30 GMT -05:00
https://www.coursehero.com/file/235913062/NSG6430-Week-3-SOAP-Costa-Cdocx/
