CONPH NSG6340/NSG6440 Subjective, Objective,
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 07/20/24 Time: 1130
L.T.
Ethnicity: Hispanic Age: 27 Sex: F
SUBJECTIVE (must complete this section)
CC: “I have been having white cottage like vaginal discharge and itching”
HPI: The patient reports experiencing white, cottage cheese-like vaginal discharge and itching for the past 5 days.
She denies any foul odor, fever, or abdominal pain. The patient states that the symptoms began after completing a
course of antibiotics for a sinus infection.
Medications:
Previous Medical History: None
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Surgeries: FAMILY HISTORY (must complete this section)
M: Alive- no
hx F: Alive-
no hx
Social History : Patient does not smoke and consumes alcohol occasionally. She does not use recreational drugs. Her
lifestyle is generally healthy, but she uses condoms inconsistently with her sexual partner. She has no history of
substance abuse or other risky behaviors.
REVIEW OF SYSTEMS (must complete this
section)
General: Denies fatigue, night sweats and Cardiovascular: Denies syncope, edema,
weakness shortness of breath, and cyanosis.
Skin: Denies rash Respiratory: Denies difficulty breathing,
shortness of breath, labored breathing,
tachypnea, wheezing, retractions, stridor, and
hemoptysis.
Eyes: Denies and visual changes, eye Gastrointestinal: Reports white discharge
drainage or eye pain and irritation
Ears: Denies pain, swelling or drainage Genitourinary/Gynecological: Denies
increased urine output, dysuria. Denies foul
urine and
hematuria
Nose/Mouth/Throat: Denies sore throat or Musculoskeletal: Denies weakness,
nasal restriction of
congestion movement, joint swelling.
Breast: Deferred Neurological: Denies abnormal activity,
abnormal movements, and changes in
strength.
Heme/Lymph/Endo: Denies swollen Psychiatric: Denies symptoms of
glands, bruising, bleeding, and edema. depression,
anxiety, mood swings, hallucinations,
delusions, or behavioral disturbances.
, OBJECTIVE (Document PERTINENT systems only,
Minimum 3)
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 07/20/24 Time: 1130
L.T.
Ethnicity: Hispanic Age: 27 Sex: F
SUBJECTIVE (must complete this section)
CC: “I have been having white cottage like vaginal discharge and itching”
HPI: The patient reports experiencing white, cottage cheese-like vaginal discharge and itching for the past 5 days.
She denies any foul odor, fever, or abdominal pain. The patient states that the symptoms began after completing a
course of antibiotics for a sinus infection.
Medications:
Previous Medical History: None
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Surgeries: FAMILY HISTORY (must complete this section)
M: Alive- no
hx F: Alive-
no hx
Social History : Patient does not smoke and consumes alcohol occasionally. She does not use recreational drugs. Her
lifestyle is generally healthy, but she uses condoms inconsistently with her sexual partner. She has no history of
substance abuse or other risky behaviors.
REVIEW OF SYSTEMS (must complete this
section)
General: Denies fatigue, night sweats and Cardiovascular: Denies syncope, edema,
weakness shortness of breath, and cyanosis.
Skin: Denies rash Respiratory: Denies difficulty breathing,
shortness of breath, labored breathing,
tachypnea, wheezing, retractions, stridor, and
hemoptysis.
Eyes: Denies and visual changes, eye Gastrointestinal: Reports white discharge
drainage or eye pain and irritation
Ears: Denies pain, swelling or drainage Genitourinary/Gynecological: Denies
increased urine output, dysuria. Denies foul
urine and
hematuria
Nose/Mouth/Throat: Denies sore throat or Musculoskeletal: Denies weakness,
nasal restriction of
congestion movement, joint swelling.
Breast: Deferred Neurological: Denies abnormal activity,
abnormal movements, and changes in
strength.
Heme/Lymph/Endo: Denies swollen Psychiatric: Denies symptoms of
glands, bruising, bleeding, and edema. depression,
anxiety, mood swings, hallucinations,
delusions, or behavioral disturbances.
, OBJECTIVE (Document PERTINENT systems only,
Minimum 3)
