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NSG 6430 Week 1 SOAP NOTE 2024 with complete solution;South University
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NSG 6430 Week 1 SOAP NOTE 2024 with complete solution;South University
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WEEK 1 SOAP NOTEName: CR Date: 3/26/2020 Time: 1100
Age: 32 Sex: Female
SUBJECTIVE
CC: "I have been having some problems the past year or so with cramps during my period”
HPI: Patient arrived at the clinic today complains has been having cramps during period, which she
states to be usual for the past year. She stated her period is every 29 days, and it lasts six to seven days.
The first day is light, but the cramping starts. Then on the second and third days the pain doesn’t allow
her to go to work. Patient states that she has two kids, aged eight and six. Both conceived natural
without difficulty. Patient denies any other pregnancies. She also denies ever had a sexually transmitted
infection or an abnormal Pap test. The patient was observed to be pleasant and with no acute distress
Medications: N/A
PMH
Allergies: NKA
Medication Intolerances: N/A
Chronic Illnesses/Major traumas: N/A
Hospitalizations/Surgeries:
Two vaginal delivery
Immunizations: Up to date all immunization.
Family History:
Father 56 hypertension.
Mother 54 hypertension, obesity.
ROS
General: Patient is 32-year-old, female, Cardiovascular: Denies any chest pain or palpitation.
Hispanic-American. Patient is alert and
capable of making decisions known. He
answers all questions
appropriately. Clothing is well kept and
appropriate for season. Patient appears
stated age, healthy, and does not appear in
any acute distress
Skin: Patient reports Skin dry and cold Respiratory: Denies any cough or shortness of breath
hand and feet
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