NSG6430_W9_A2_Askew_J SOAP NOTE
LATEST WITH CORRECT ANSWERS
SOAP NOTE
Name: JM Date: 9/11/18 Time: 1530
Age: 47 Sex: Female
SUBJECTIVE
CC:
“I am having night sweats and hot flashes.”
HPI:
47-year-old female presenting with a chief complaint of night sweats and hot
flashes for the past month. Her last menstrual period was 1/01/18 with some spotting in
the month after but nothing since then. She states she has been getting extremely
emotional and does not know why.
Medication: (list with reason for med)
Denies use of medications takes Tylenol for occasional headaches.
PMH: Denies
Allergies: No known Drug Allergies, no food or insect allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas:
Patient denies any medical trauma
OBGYN History: G1P1, Last pap in 2017, Mammogram 2017, LMP 1/01/18
Immunizations: all immunizations up to date. Tdap, MMR, Polio, and Hep B.
Chronic Health Problems: Denies
Hospitalization/Surgeries: Denies any surgeries or hospitalizations. Vaginal delivery in
1994
Family History: Mother deceased. Father unknown
Social History:
Social history is negative for ETOH. Denies present use of tobacco and illicit drugs.
States she does not exercise regularly, and is not on a special diet although she tries to eat
healthy. Works as a medical assistant in a local dentist office. Lives with husband.
ROS
This study source was downloaded by 100000815611969 from CourseHero.com on 01-29-2023 23:35:44 GMT -06:00
https://www.coursehero.com/file/33979998/NSG6430-W9-A2-Askew-Jdocx/
, NSG6430_W9_A2_Askew_J SOAP NOTE
LATEST WITH CORRECT ANSWERS
General: Cardiovascular:
Night Sweats and chills. Denies weight Denies any episodes of chest pain,
gain, fatigue, fever, chills. palpitations, syncope or orthopnea.
This study source was downloaded by 100000815611969 from CourseHero.com on 01-29-2023 23:35:44 GMT -06:00
https://www.coursehero.com/file/33979998/NSG6430-W9-A2-Askew-Jdocx/
LATEST WITH CORRECT ANSWERS
SOAP NOTE
Name: JM Date: 9/11/18 Time: 1530
Age: 47 Sex: Female
SUBJECTIVE
CC:
“I am having night sweats and hot flashes.”
HPI:
47-year-old female presenting with a chief complaint of night sweats and hot
flashes for the past month. Her last menstrual period was 1/01/18 with some spotting in
the month after but nothing since then. She states she has been getting extremely
emotional and does not know why.
Medication: (list with reason for med)
Denies use of medications takes Tylenol for occasional headaches.
PMH: Denies
Allergies: No known Drug Allergies, no food or insect allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas:
Patient denies any medical trauma
OBGYN History: G1P1, Last pap in 2017, Mammogram 2017, LMP 1/01/18
Immunizations: all immunizations up to date. Tdap, MMR, Polio, and Hep B.
Chronic Health Problems: Denies
Hospitalization/Surgeries: Denies any surgeries or hospitalizations. Vaginal delivery in
1994
Family History: Mother deceased. Father unknown
Social History:
Social history is negative for ETOH. Denies present use of tobacco and illicit drugs.
States she does not exercise regularly, and is not on a special diet although she tries to eat
healthy. Works as a medical assistant in a local dentist office. Lives with husband.
ROS
This study source was downloaded by 100000815611969 from CourseHero.com on 01-29-2023 23:35:44 GMT -06:00
https://www.coursehero.com/file/33979998/NSG6430-W9-A2-Askew-Jdocx/
, NSG6430_W9_A2_Askew_J SOAP NOTE
LATEST WITH CORRECT ANSWERS
General: Cardiovascular:
Night Sweats and chills. Denies weight Denies any episodes of chest pain,
gain, fatigue, fever, chills. palpitations, syncope or orthopnea.
This study source was downloaded by 100000815611969 from CourseHero.com on 01-29-2023 23:35:44 GMT -06:00
https://www.coursehero.com/file/33979998/NSG6430-W9-A2-Askew-Jdocx/
