Walden UniversityNURS 6551NURS 6551 Wk 11 SOAP Note.

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Running head: WEEK 11 SOAP NOTE Week 11 SOAP Note STUDENT NURS 6551 Primary Care of Women Walden University February 4, 2021 WEEK 11 SOAP NOTE 2 Week 11 SOAP Initials: R. B. Sex: Female Age: ... 33 SUBJECTIVE DATA: Chief Complaint (CC): “Abnormal vaginal bleeding for two weeks.” History of Present Illness (HPI): 33-year-old African American female is seen in office with a complaint of abnormal vaginal bleeding for two weeks. The patient states that initially the bleeding was mild but now alternates between moderate to heavy bleeding. The patient denies any factors that alleviates or worsens the bleeding. She also denies any associated factors or manifestations. Medications: Protonix 40mg daily, diphenhydramine 25mg, 1-2 tabs at bedtime as needed for insomnia. Allergies: denies any known medication or food allergies. Past Medical History (PMH): GERD and insomnia. Denies recent hospitalizations. Past Surgical History (PSH): Appendectomy in 2003. OB/GYN History: Nulligravida. Patient states that her menstrual cycle is irregular and that bleeding during menses lasts 5-6 days with moderate bleeding. The patient also reports that she has been bleeding for two weeks and that the bleeding has increased from mild to moderate/heavy flow. She states that she has a period once every two to three months. Denies a history of sexually transmitted infections and reports that she had one sexual partner with her husband of 10 years. Patient states that she does not use contraceptives since she has never conceived in the past. Personal/Social History: Patient denies smoking or the use of alcohol or illicit drugs. The patient also states that she does not exercise but that her diet consists of baked meats, fruits and vegetables, and she usually drink water or sports drinks. [Show More]

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