Exam (elaborations)
NSG6430 WEEK 3 SOAP SAEZ SULEINY EXAM UPDATE| RATED A+
- Course
- Institution
NSG6430 WEEK 3 SOAP SAEZ SULEINY EXAM UPDATE| RATED A+
[Show more]
Content preview
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
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Abugelangel. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $8.00. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
80202 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now