NRNP 6552: Advanced Nurse Practice in Reproductive Health
Care
Episodic/Focused SOAP Note Template
Week 4 Forum/Case Study: STI
Patient Information: Investigation
Initials: S. L. Age: 24 Sex: Female Race: Caucasian
S.
CC (chief complaint): Postcoital bleeding, sore throat, fever
HPI: 24-year-old Caucasian female, presenting to the OBGYN clinic for regular care. She
reports postcoital bleeding for the past six weeks, a sore throat for the past three weeks, with a
fever for a day or two.
Location: Vagina,
throat Onset: 3 – 6
weeks Character: Sore
Associated signs and symptoms: Fever, postcoital bleeding, sore throat
Timing: After sex
Exacerbating/relieving factors: Tylenol
Severity: 6/10 pain scale
Current Medications: No prescription medication. OTC Pamprin & Tylenol prn
Allergies: NKDA
PMHx: No medical history
Soc & Substance Hx: Full-time as an administrative assistant. Her social history is remarkable
for cigarette smoking, ½ packs per day (PPD) since age 14, ETOH only on weekends, 6-8 hard
liquor/daily, and marijuana smoking. She jogs 3-4 times a week, “occasionally” uses
sunscreen. She uses safe driving practices by wearing her seat belt. She denies texting and cell
phone use while driving, and has support systems available.
Fam Hx: Non-contributary
Surgical Hx: No surgical history
Mental Hx: Denies any history of anxiety, depression, or any other mental health history. No
sleep problems, delusions, or suicidal thoughts.
, NRNP 6552: Advanced Nurse Practice in Reproductive Health
Care
Violence Hx: Denies concerns or issues about safety in personal, home, community, or sexual,
current and past
Reproductive Hx: Onset of menses age 13, menses every 28-32 days, lasting 4-6 days, using
three tampons daily. She has some cramping during her menses, for which she
takes OTC Pamprin.
ROS
GENERAL: Reports recent fever lasting one to two days. Denies chills, or night sweats. No
recent weight gain or loss of significance.
HEENT: Head: Normocephalic Eyes: Denies change in vision, sclerae white, reports no
changes in eyes; denies glaucoma, double vision, floaters, excessive tearing, or dryness. Ears:
Denies hearing loss, no recent ear infections, pain, tenderness, tinnitus, or discharge from ears.
Nose: Denies history of nasal polyps, epistaxis, or sinus infection; denies sneezing congestion,
runny nose Throat: Reports sore throat for the past three weeks. Last dental exam 1/2020.
Denies oral lesions, bleeding gums, or gingivitis. Denies any problems with chewing or
swallowing.
SKIN: Denies rashes, itching, lesions, open sores, or bruising. Denies history of skin cancer.
CARDIOVASCULAR: Denies chest discomfort, palpitations, edema, or a heart murmur.
RESPIRATORY: Denies dyspnea, cough, sputum production, or hemoptysis.
GASTROINTESTINAL: Denies nausea, vomiting, diarrhea, blood in the stool, or constipation.
No complaints of abdominal pain or changes in bowel patterns. Reports regular bowel
movements.
GENITOURINARY: No change in urinary pattern. Denies dysuria or incontinence.
NEUROLOGICAL: Denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the
extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness. No reports of
arthritis, gout, or limitations in his range of motion. No history of trauma or fractures. Denies
arthralgia or myalgia
HEMATOLOGIC: No history of anemia, bruising, clotting difficulties, or transfusions.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression and anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or
polydipsia. Denies hormonal changes or therapies.
REPRODUCTIVE: Reports of vaginal discharge. She is sexually active.
ALLERGIES: No hives, eczema, or rhinitis.
Care
Episodic/Focused SOAP Note Template
Week 4 Forum/Case Study: STI
Patient Information: Investigation
Initials: S. L. Age: 24 Sex: Female Race: Caucasian
S.
CC (chief complaint): Postcoital bleeding, sore throat, fever
HPI: 24-year-old Caucasian female, presenting to the OBGYN clinic for regular care. She
reports postcoital bleeding for the past six weeks, a sore throat for the past three weeks, with a
fever for a day or two.
Location: Vagina,
throat Onset: 3 – 6
weeks Character: Sore
Associated signs and symptoms: Fever, postcoital bleeding, sore throat
Timing: After sex
Exacerbating/relieving factors: Tylenol
Severity: 6/10 pain scale
Current Medications: No prescription medication. OTC Pamprin & Tylenol prn
Allergies: NKDA
PMHx: No medical history
Soc & Substance Hx: Full-time as an administrative assistant. Her social history is remarkable
for cigarette smoking, ½ packs per day (PPD) since age 14, ETOH only on weekends, 6-8 hard
liquor/daily, and marijuana smoking. She jogs 3-4 times a week, “occasionally” uses
sunscreen. She uses safe driving practices by wearing her seat belt. She denies texting and cell
phone use while driving, and has support systems available.
Fam Hx: Non-contributary
Surgical Hx: No surgical history
Mental Hx: Denies any history of anxiety, depression, or any other mental health history. No
sleep problems, delusions, or suicidal thoughts.
, NRNP 6552: Advanced Nurse Practice in Reproductive Health
Care
Violence Hx: Denies concerns or issues about safety in personal, home, community, or sexual,
current and past
Reproductive Hx: Onset of menses age 13, menses every 28-32 days, lasting 4-6 days, using
three tampons daily. She has some cramping during her menses, for which she
takes OTC Pamprin.
ROS
GENERAL: Reports recent fever lasting one to two days. Denies chills, or night sweats. No
recent weight gain or loss of significance.
HEENT: Head: Normocephalic Eyes: Denies change in vision, sclerae white, reports no
changes in eyes; denies glaucoma, double vision, floaters, excessive tearing, or dryness. Ears:
Denies hearing loss, no recent ear infections, pain, tenderness, tinnitus, or discharge from ears.
Nose: Denies history of nasal polyps, epistaxis, or sinus infection; denies sneezing congestion,
runny nose Throat: Reports sore throat for the past three weeks. Last dental exam 1/2020.
Denies oral lesions, bleeding gums, or gingivitis. Denies any problems with chewing or
swallowing.
SKIN: Denies rashes, itching, lesions, open sores, or bruising. Denies history of skin cancer.
CARDIOVASCULAR: Denies chest discomfort, palpitations, edema, or a heart murmur.
RESPIRATORY: Denies dyspnea, cough, sputum production, or hemoptysis.
GASTROINTESTINAL: Denies nausea, vomiting, diarrhea, blood in the stool, or constipation.
No complaints of abdominal pain or changes in bowel patterns. Reports regular bowel
movements.
GENITOURINARY: No change in urinary pattern. Denies dysuria or incontinence.
NEUROLOGICAL: Denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the
extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness. No reports of
arthritis, gout, or limitations in his range of motion. No history of trauma or fractures. Denies
arthralgia or myalgia
HEMATOLOGIC: No history of anemia, bruising, clotting difficulties, or transfusions.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression and anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or
polydipsia. Denies hormonal changes or therapies.
REPRODUCTIVE: Reports of vaginal discharge. She is sexually active.
ALLERGIES: No hives, eczema, or rhinitis.
