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Nursing 5333 Family Nursing I Diagnostic Reasoning Case Study $11.49   Add to cart

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Nursing 5333 Family Nursing I Diagnostic Reasoning Case Study

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Diagnostic Reasoning Case Study Jennifer Hood University of Texas Arlington College of Nursing and Health Innovation Nursing 5333 Family Nursing I Kashiris Perryman, DNP, APRN, FNP-PC June 12, 2021 Soap Note S/ Identifying Information: Martha 26 yo female DOB July 12, 1995 Fa...

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  • April 4, 2023
  • 12
  • 2022/2023
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Diagnostic Reasoning Case Study



Jennifer Hood

University of Texas Arlington College of Nursing and Health

Innovation Nursing 5333 Family Nursing I

Kashiris Perryman, DNP, APRN, FNP-

PC June 12, 2021

, 2


Soap Note
S/ Identifying Information:

Martha
26 yo female Family Hx:
DOB July 12, 1995
Mother--DM (Alive)
Father—COPD (Alive)
Brother—No preexisting conditions (Living)
Personal/Social Hx:
Chief Complaint/RFE: College Graduate
vaginal burning x 3 days Currently employed as a schoolteacher
Financially secure
Hx Present Illness: Lives alone in apartment
26 yo female comes into clinic today in no Feels safe at home and in current relationship
acute distress. Reports vaginal burning for Heterosexual
the last 3 days. Is sexually active and last Monogamous relationship with boyfriend
sexual intercourse was one week ago. Denies smoking and drug abuse
Socially drinks: 1-2 glasses of wine/weekend


CURRENT HEALTH
Medications:
No Medications, vitamins, or herbal supplements

Allergies: NKDA. Seasonal allergies in the Spring

Last PE & Screenings: Last PAP 2016 (age 21): Negative

Immunization Status: Has not received HPV vaccine

LMP & Birth Control (if applicable)
PMH
Illnesses & Trauma: None
Hospitalizations/Surgeries: tonsillectomy 2002 (age 7)
OB Hx/Sexual Hx: Sexually active since age 15. Has had 2 relationships this past year. Last
sexual intercourse: 1 week ago
Emotional/Psy Hx:
REVIEW OF SYSTEMS
General Denies fever, chills, nausea, vomiting, and diarrhea
Nutrition defer
Skin/Hair/Nails defer
HEENT defer
HEAD –
EYES—

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