NURSING 491 (NURSING 491)

Week 5 SOAP Note

Women’s Health Mini SOAP Notes ICD 10: N39.0 S: Burning and pain with urination for 3 three days. Stated that her urine looks cloudy and has a foul odor. Denies fever, nausea, vomiting, myalgia, flank pain, blood in urine, any vaginal discharge, and, vaginal/vulvar irritation. She is sexually active, has same partner for last 4 years. G1P1001, with normal vaginal delivery. Menarche age 11. Last menses one week ago; regular 4- 5 days. Tested for STD one year ago. Negative for Chlamydia an...

F_Escobar_N491_M3|Module 3: Orlando Case Study & Nursing in the 50’s and 60’s

Imogene King’s Conceptual Systems & Theory of Goal Attainment Fernando Escobar Aspen University N491: Concepts and Theories in Nursing

“My cycles are so erratic and irregular.” HPI: AA is a 19 year old, Hispanic female who presents for her first gynecological exam with complaints of irregular periods. Pt. has no previous medical hx. Pt. reports LMP was two weeks ago. Reports she only has 2-3 periods a year on average since beginning her cycles at 16 years old. Her cycles generally consist of 2-3 days of moderate bleeding in which one tampon last a few hours, followed by 1-2 days of light bleeding and spotting. Pt. re...

Module 3: Orlando Case Study & Nursing in the 50’s and 60’s

TA is a 26-month-old male with Down syndrome who has presented with his mother’s statement of “a tummy ache”. Mother has also noted that TA has been lethargic, whining and has a poor appetite for the last two days. She continues on stating that TA fell out of this bed while taking a nap. TA appears listless and pale during examination. TA has a history of atrioventricular septal defect (complete), status-post surgical repair; congestive heart failure, resolved following surgery; and, globa...

TA is a 26-month-old male with Down syndrome who has presented with his mother’s statement of “a tummy ache”. Mother has also noted that TA has been lethargic, whining and has a poor appetite for the last two days. She continues on stating that TA fell out of this bed while taking a nap. TA appears listless and pale during examination. TA has a history of atrioventricular septal defect (complete), status-post surgical repair; congestive heart failure, resolved following surgery; and, globa...

WOMEN’S HEALTH MINI SOAP NOTES