South University, Savannah - NSG 6430 Week 6 SOAP NOTE: Complete

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South University, Savannah - NSG 6430 Week 6 SOAP NOTE Name: XX Date: 02/21/2019 Time: 12:30pm Age: 44 Sex: Female SUBJECTIVE CC: “I am here for heavy period with clots for two da... ys”. HPI: The patient is a 44-year-old black female G3 P3 with PMH of DM and PGH of heavy period for a year presents to clinic with abdominal pain and sudden onset of ‘miscarriage-like’ heavy vaginal bleeding with clots 2 days ago. She states two days back she feels sudden cramps like lower abdominal pain, around 6-7/10 in intensity, radiating to her back and inner thighs with spotting that turn into heavy vaginal bleeding with clots. She still has pain, but it is 4/10 and is controlled with 400mg Motrin. She is taking the Motrin every 6 to 8 hours. She reports her periods were heavy for long time but inter-menstrual spotting per vagina started since IUD insertion 1 year ago. Her both deliveries were normal term deliveries. Medications: Medication Dose Direction Indication Classification of Drug Glucophage 500mg PO BID For diabetes Metformin- oral anti-hyperglycemic agent Ibuprofen 400mg Oral PRN for pain NSAIDs PMH Allergies: None Medication Intolerances: None Chronic Illnesses/Major traumas DM Hospitalizations/Surgeries Patient hospitalized for cholecystectomy 8 years back. Family History Patient’s mother had ovarian cancer died at the age of 56. Her father died of stroke at the aged 65 years. She has four siblings and they are ok. Social History She works as a teacher, sexually active, married and living with her husband. Former smoker ½ a PPD but quit 10 years ago. Denies use of illicit drugs. She exercises regularly five days a week for 30-40 minutes in gym. She tries to eat organic healthy food but sometimes with the friends she enjoys junk food. Her immunization up-to-date with flu shot in October, 2018. [Show More]

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