Women’s Health Case Study

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SU_NSG6430_week2_A2_Pandey_R-Redone2.docx

SOAP NOTE

Name: MT

Date:12/3/19

Time: 0930

Encounter 2

Age: 32

Gender: Female

PARTICULAR

CC:

“I am in requirement of your assistance to get help with birth control. There are so many choices unfortunately, I do not know which one to take.”

HPI: Female aged thirty two years old who is Asian American applies to the clinic so that she can start birth control.

Prescription: (reasons for prescription)

PT is not taking any medication currently

PMH: None

Allergies: Does not have any nutriment or medicine antipathies

Suppository Prejudices: None

Prolonged Sicknesses/Main traumas:

Patient rejects to any therapeutic disturbance

Enduring Health Problems: No identified fleeting health complications

Hospitalization/Surgical procedure: Not known.

Family History: Mother Healthy. Father HTN. Sister Healthy. Brother autism

Social History:

Societal antiquity is nil for ETOH where she repudiates present and, or past use of illicit drugs and she negates current use of tobacco. Also, she claims to do exercise on a regular basis but not on any specified diet. Currently , Pt is in Financial accounts class

ROS

General:

The pt repudiates fatigue, fever, night sweats, chills, weight change and energy level.

Cardiovascular:

She repudiates any experiences of syncope, palpitations, chest pain or orthopnea.

Skin:

The patients denies any signs of skin abrasions.

Respiratory:

The patient disagrees to have dyspnea and cough

Eyes:

Patient states no alterations in blurred visualization or dual vision.

Abdominal:

Patient denies having nausea, vomiting any bowel changes change in hungriness

Ears:

No recent discharge from ears, pressure loss of hearing and tinnitus

Genitourinary/Postnatal:

Patient denies any itching, burning or …