NURS 6512 Advanced Health Assessment_ Assessing the Genitalia and Rectum: Focused SOAP Note Template

Assessing the Genitalia and Rectum Advanced Health Assessment Assessing the Genitalia and Rectum Episodic/Focused SOAP Note Template Patient Information: JW Age: 21 Sex: Female Race: Caucasian S. CC(chief complaint) “I have bumps on my bottom that I want to have checked out. ” HPI: This 21-year-old Caucasian female presents to our clinic complaining of painless, rough bumps on her genital region. The onset of these bumps was approximately one week ago. JW reports being sexually active with more than one partner over the past year. She also has a history of chlamydia 2 years ago with completed treatments. She reports being sexually active since the age of 18 years of age. Current Medications: Symbicort 160/4.5mcg PO twice daily Allergies: NKDA PMHx: Chlamydia, Asthma Soc Hx: Denies tobacco use; occasional ETOH, married, 3 children (1 girl, 2 boys) Fam Hx: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD ROS: Example of Complete ROS: GENERAL: Denies weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: Reports bumps on around genital region, no vaginal discharge reported.