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NSG6430 WEEK 3 SOAP SAEZ SULEINY EXAM UPDATE| RATED A+
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NSG6430 WEEK 3 SOAP SAEZ SULEINY EXAM UPDATE| RATED A+
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1Student Name: Suleiny Saez Course: NSG6430
Patient Name: DH Date: 8/22/2023 Time: 1030am
Ethnicity: Latino Age: 20 years Sex: Female
SUBJECTIVE (must complete this section)
CC: "I haven't had a cycle in the last three months."
HPI: A 20-year-old visited the clinic complaining of irregular periods. The patient reports having her last menstrual cycle on May 2, 2023. She stated that her menses had been regular since beginning her period at 12. Her cycles consist of 2-3 days of moderate bleeding and two more days of spotting. DH reports cramping on a 4/10 pain scale; she manages it with Acetaminophen. The patient denies vaginal discharge, galactorrhea, weight gain, and heat or cold intolerance. She states having issues with acne in the past year but has been able to manage it with Cerave face wash and salicylic acid. The patient uses condoms as a contraception method. She also states that she moved to a new apartment and started a new job,
and that's when she noticed her periods were missing. Medications: Acetaminophen every 6 hours for cramping. Previous Medical History: No allergies, diabetes, or urinary incontinence Allergies: No known allergies Medication Intolerances: denies
Chronic Illnesses/Major traumas: denies Hospitalizations/Surgeries denies OB-GYN History
Menarche – 12 years. Birth control pills- none, uses condoms as a contraceptive method
She reports being sexually active only with her boyfriend G0P0
FAMILY HISTORY (must complete this section)
M: 47, no medical history, regular cycles Surgerie
s:This study source was downloaded by 100000850786994 from CourseHero.com on 09-28-2023 14:54:26 GMT -05:00
https://www.coursehero.com/file/211134650/NSG6430-Week-2-SOAP-Saez-Suleinydocx/CONPH NSG6330/NSG6430 Subjective, Objective, Assessment, Plan (SOAP) Notes
EXAM 2
MGM, 78, died five years ago from a stroke F: 50, hypertension PGM: 85, Diabetes mellitus PGF: d, 81, CHF and KD
Social History: DH is a nursing student and reports starting a new job 3 three months ago in a medical office. She also said she moved to a new apartment with her boyfriend of 5 years. The patient reports experiencing various life challenges, such as increased study hours and lack of sleep. She says she drinks two glasses of caffeine daily but denies alcohol, tobacco, or illicit drugs. Tries to eat a healthy diet and exercise 4 times a week for an hour. REVIEW OF SYSTEMS (must complete this section)
General: Denies any change in appetite or weight Cardiovascular: Denies peripheral edema, orthopnea, or chest pain. Skin: Denies any lacerations, rashes, or lesions. Respiratory: denies cough or shortness of breath
Eyes: Denies eye pain, blurred vision, or redness. Gastrointestinal: Denies bloating, heartburn, or GERD. Ears: Denies ear pain, ear infection, or ringing. Genitourinary/Gynecological: Reports vaginal dryness but denies urgent urination or abnormal vaginal discharge, report irregular cycles and mild cramping. Nose/Mouth/Throat: Denies voice changes, stuffy nose, or mouth ulcerations.Musculoskeletal: Denies stiffness or weakness
Breast: denies breast tenderness, lumps, and nipple dischargeNeurological: Reports irritability but denies tremors or anxiety
Heme/Lymph/Endo: denies heat or cold intolerance, polyuria, or polydipsia Psychiatric: denies anxiety, depression, or inability to concentrate
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: 132Height: 5'6"BMI: 21.3BP:
119/82Temp: 97.5 FPulse: 72Resp: 18
General Appearance: well dressed and groomed, alert and oriented, pleasant Skin: No lacerations, abrasions, or lesions noted; warm to touch
HEENT: Head: Atraumatic, non-tender, hair symmetrical, no balding noted
Eyes: conjunctiva pink, no jaundice. Ears: pearly gray tympanic membrane.This study source was downloaded by 100000850786994 from CourseHero.com on 09-28-2023 14:54:26 GMT -05:00
https://www.coursehero.com/file/211134650/NSG6430-Week-2-SOAP-Saez-Suleinydocx/
EXAM
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