A Clinical Soap Note on Abnormal Uterine and Vaginal Bleeding_CARLOS
Running head: VAGINAL BLEEDING
A Clinical Soap Note on Abnormal Uterine and Vaginal Bleeding
Student’s Name
Institutional Affiliation
This study source was downloaded by 100000832558064 from CourseHero.com on 05-24-2022 06:02:14 GMT -05:00
https://www.coursehero.com/file/26128264/A-Clinical-Soap-Note-on-Abnormal-Uterine-and-Vaginal-Bleeding-CARLOSdocx/
, 2
VAGINAL BLEEDING
Patient information
Name: Ms. Armando
Age: 26
Chief Complaint: A Caucasian lady complaining of periods taking long time to dry
History of Present Illness: The 26 year old female presented herself to the clinic and complained
of having prolonged menses and losing a lot of blood than what she has been witnessing earlier.
She says that this is her second menses that she has experienced this abnormality. She says that
her menses are taking up to 8 days and hence losing a lot of blood and this has scared her. In
addition, the patient reports that she is frequently soaking up the pads and hence using so many
per day. As a result, the lady reports that she is occasionally feeling very weak and having
headache. “This month my period took 45 days to come and this have kept me in a distress”. I
always use some Motrin and ibuprofen to relieve the headache”. “I am currently sexually active
with one partner and the bleeding tend to aggravate after sex and uses birth control pills to
prevent pregnancy”. Since she was a child she has been obese and is a student and rarely does
she have physical exercises.
Past Medical History: The patient has been obese since the young age, at the age of 14 she had a
fracture on her right arm and hospitalized for 2 days. At the age of 23 years she had some
infections on her vulva having a lump that was painless but was treated. She was diagnosed of
type 2 diabetes at 20 years and is currently managing the health problem using diet.
Social History: The patient reports that she is a smoker and is trying to cease the practice. She is
single with no child but has a boyfriend who she frequently have sex with. She is currently in her
last semester in a nursing college. She lives with her mother.
This study source was downloaded by 100000832558064 from CourseHero.com on 05-24-2022 06:02:14 GMT -05:00
https://www.coursehero.com/file/26128264/A-Clinical-Soap-Note-on-Abnormal-Uterine-and-Vaginal-Bleeding-CARLOSdocx/
Running head: VAGINAL BLEEDING
A Clinical Soap Note on Abnormal Uterine and Vaginal Bleeding
Student’s Name
Institutional Affiliation
This study source was downloaded by 100000832558064 from CourseHero.com on 05-24-2022 06:02:14 GMT -05:00
https://www.coursehero.com/file/26128264/A-Clinical-Soap-Note-on-Abnormal-Uterine-and-Vaginal-Bleeding-CARLOSdocx/
, 2
VAGINAL BLEEDING
Patient information
Name: Ms. Armando
Age: 26
Chief Complaint: A Caucasian lady complaining of periods taking long time to dry
History of Present Illness: The 26 year old female presented herself to the clinic and complained
of having prolonged menses and losing a lot of blood than what she has been witnessing earlier.
She says that this is her second menses that she has experienced this abnormality. She says that
her menses are taking up to 8 days and hence losing a lot of blood and this has scared her. In
addition, the patient reports that she is frequently soaking up the pads and hence using so many
per day. As a result, the lady reports that she is occasionally feeling very weak and having
headache. “This month my period took 45 days to come and this have kept me in a distress”. I
always use some Motrin and ibuprofen to relieve the headache”. “I am currently sexually active
with one partner and the bleeding tend to aggravate after sex and uses birth control pills to
prevent pregnancy”. Since she was a child she has been obese and is a student and rarely does
she have physical exercises.
Past Medical History: The patient has been obese since the young age, at the age of 14 she had a
fracture on her right arm and hospitalized for 2 days. At the age of 23 years she had some
infections on her vulva having a lump that was painless but was treated. She was diagnosed of
type 2 diabetes at 20 years and is currently managing the health problem using diet.
Social History: The patient reports that she is a smoker and is trying to cease the practice. She is
single with no child but has a boyfriend who she frequently have sex with. She is currently in her
last semester in a nursing college. She lives with her mother.
This study source was downloaded by 100000832558064 from CourseHero.com on 05-24-2022 06:02:14 GMT -05:00
https://www.coursehero.com/file/26128264/A-Clinical-Soap-Note-on-Abnormal-Uterine-and-Vaginal-Bleeding-CARLOSdocx/
