Exam (elaborations)
Nsg 6430 week 6 soap note 2024 with complete solution; south university
Nsg 6430 week 6 soap note 2024 with complete solution; south university
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SOAP NOTEName: KR Date: 8/22/20 Time: 1000
Age: 17 Sex: Female
SUBJECTIVE
CC:
“I've been having a terrible left lower abdominal pain, it started 4 days ago, and I was given
antibiotics, but it didn’t help.”
HPI:
The patient is a 17-year-old Caucasian female who came into the office c/o moderate left lower
and mid pelvic pain level of 10/10. The pain comes suddenly, sharp with some intermittent
relief. Nothing seems to make it better or worse. She has taken ibuprofen and heat packs but no
changes. She also complained of nausea and vomiting, and nonwhite vaginal discharge. No
history of sexually transmitted infections, surgery, and medical conditions.
Medications:
Doxycycline 1000mg po daily – Pelvic inflammatory disease
Ibuprofen 800mg po q6h - Pain
PMH
Allergies:
NKA
Medication Intolerances:
None listed
Chronic Illnesses/Major traumas
None
Hospitalizations/Surgeries
None
Family History
This study source was downloaded by 100000851720696 from CourseHero.com on 06-21-2024 18:48:49 GMT -05:00
https://www.coursehero.com/file/68750936/NSG-6430-Week-6-SOAP-notedocx/
, Mother (alive) – HTN
Father (alive) – Hyperlipidemia
Sister and brother - healthy
Social History
Pt is single and lives at home with her parents. She is sexually active with four partners. She
works part time at McDonald and go to school (10th grade). Pt denies any cigarette, alcohol, or
illicit drug use. m
ROS
General Cardiovascular
Patient appear very frustrated and in moderate Denies any murmur, bruits, chest pain, edema,
to severe pain. Denies fatigue, night sweat and or palpitations,
recent weight gain or loss.
Skin Respiratory
Denies any rash, delayed healing, itching, Denies, SOB, exposure to TB, cough,
bruising, skin discoloration, moles, or hemoptysis, wheezing.
lesions.
Eyes Gastrointestinal
Denies use of corrective lenses, blurred vision, C/o moderate to severe lower abdominal pain,
or visual disturbances of any kind. nausea, and vomiting. Denies dysphagia, or
abnormal stools. Constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, black
tarry stools.
Ears Genitourinary/Gynecological
Denies hearing loss, ringing in the ear, C/o nonwhite vaginal discharge. Denies any
discharge, or ear pain. burning, frequency, hesitancy, nocturia or
urgency with urination. Sexually active, denies
contraceptive use. No history pap smear exam,
STIs and pregnancy, etc.
Nose/Mouth/Throat Musculoskeletal
This study source was downloaded by 100000851720696 from CourseHero.com on 06-21-2024 18:48:49 GMT -05:00
https://www.coursehero.com/file/68750936/NSG-6430-Week-6-SOAP-notedocx/
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