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NSG 6020 Week 5 2021 Exam Quiz. Score A.
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NSG 6020 Week 5 Exam Quiz.Score A.
, Genevieve Leetham’s Soap Note Week 5 NSG 6020
Name: J.S. Date: 7/10/18 Time: 1601
Age: 57 Sex: Female
SUBJECTIVE:
Chief Complaint: “I have had oily, runny stools for 3 months”.
HPI: The patient is a 57 year old female who presents to the clinic today for oily stools for the
last 3 months. The patient reports nothing makes it better or worse, and that somedays her stools
are more solid, usually 2-3 days of the week, and other days they are quite liquid, and the toilet
bowl is always full of a yellow oily substance, and when she wipes, there is bright yellow oil on
the toilet paper. She also reports generalized abdominal pain that comes and goes at least once
each day. It does not seem to get worse in any position, and seems to get worse a few hours after
eating a meal. The patient is status post 6 months laparoscopic cholecystectomy, and reports she
has lost 80 pounds since then by eating a more healthy diet, and by exercising every day for at
least 30 minutes.
Medications: None
Allergies: Penicillin and sulfa. Patient reports she gets hives with both of these medications.
Chronic Illnesses: none
Hospitalizations: 6 months ago had cholecystectomy for several gallstones and acute
cholecystitis. The patient denies any kidney, heart, lung, thyroid problems, stroke, diabetes,
hypertension, and mental illnesses. The patient is a gravida 3 para 3, and denies any history of
spontaneous abortions.
Family History: The patient states her mother has hypertension but otherwise healthy and her
Dad has low thyroid. She denies any family history for diabetes, heart disease, lung disease,
kidney disease, mental illness, cancer, and mental illness. The patient also reports she is an only
child.
Social History: The patient lives in an apartment with her husband and teenage son. She reports
she has been in a monogamous relationship for over 30 years. She reports she graduated high
school and never went to college, and works as a receptionist at a local business. She denies any
history of drug or alcohol use, and has never used tobacco. The patient reports she feels safe in
her current home life, and denies questions about self-harm, or anyone doing harm to her.
Review Of Systems:
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