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Diagnostic Reasoning Case Study
Jennifer Hood
University of Texas Arlington College of Nursing and Health
Innovation Nursing 5333 Family Nursing I
Kashiris Perryman, DNP, APRN, FNP-
PC June 12, 2021
, 2
Soap Note
S/ Identifying Information:
Martha
26 yo female Family Hx:
DOB July 12, 1995
Mother--DM (Alive)
Father—COPD (Alive)
Brother—No preexisting conditions (Living)
Personal/Social Hx:
Chief Complaint/RFE: College Graduate
vaginal burning x 3 days Currently employed as a schoolteacher
Financially secure
Hx Present Illness: Lives alone in apartment
26 yo female comes into clinic today in no Feels safe at home and in current relationship
acute distress. Reports vaginal burning for Heterosexual
the last 3 days. Is sexually active and last Monogamous relationship with boyfriend
sexual intercourse was one week ago. Denies smoking and drug abuse
Socially drinks: 1-2 glasses of wine/weekend
CURRENT HEALTH
Medications:
No Medications, vitamins, or herbal supplements
Allergies: NKDA. Seasonal allergies in the Spring
Last PE & Screenings: Last PAP 2016 (age 21): Negative
Immunization Status: Has not received HPV vaccine
LMP & Birth Control (if applicable)
PMH
Illnesses & Trauma: None
Hospitalizations/Surgeries: tonsillectomy 2002 (age 7)
OB Hx/Sexual Hx: Sexually active since age 15. Has had 2 relationships this past year. Last
sexual intercourse: 1 week ago
Emotional/Psy Hx:
REVIEW OF SYSTEMS
General Denies fever, chills, nausea, vomiting, and diarrhea
Nutrition defer
Skin/Hair/Nails defer
HEENT defer
HEAD –
EYES—
Diagnostic Reasoning Case Study
Jennifer Hood
University of Texas Arlington College of Nursing and Health
Innovation Nursing 5333 Family Nursing I
Kashiris Perryman, DNP, APRN, FNP-
PC June 12, 2021
, 2
Soap Note
S/ Identifying Information:
Martha
26 yo female Family Hx:
DOB July 12, 1995
Mother--DM (Alive)
Father—COPD (Alive)
Brother—No preexisting conditions (Living)
Personal/Social Hx:
Chief Complaint/RFE: College Graduate
vaginal burning x 3 days Currently employed as a schoolteacher
Financially secure
Hx Present Illness: Lives alone in apartment
26 yo female comes into clinic today in no Feels safe at home and in current relationship
acute distress. Reports vaginal burning for Heterosexual
the last 3 days. Is sexually active and last Monogamous relationship with boyfriend
sexual intercourse was one week ago. Denies smoking and drug abuse
Socially drinks: 1-2 glasses of wine/weekend
CURRENT HEALTH
Medications:
No Medications, vitamins, or herbal supplements
Allergies: NKDA. Seasonal allergies in the Spring
Last PE & Screenings: Last PAP 2016 (age 21): Negative
Immunization Status: Has not received HPV vaccine
LMP & Birth Control (if applicable)
PMH
Illnesses & Trauma: None
Hospitalizations/Surgeries: tonsillectomy 2002 (age 7)
OB Hx/Sexual Hx: Sexually active since age 15. Has had 2 relationships this past year. Last
sexual intercourse: 1 week ago
Emotional/Psy Hx:
REVIEW OF SYSTEMS
General Denies fever, chills, nausea, vomiting, and diarrhea
Nutrition defer
Skin/Hair/Nails defer
HEENT defer
HEAD –
EYES—
