CONPH NSG6020 SOAP Notes Subjective, Objective,
Assessment, Plan Verified Study Solutions
CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Wisline Dorvil Course: NSG6430
Patient Name: (Initials ONLY) J. C Date:3/20/2025 Time: 9. AM
Ethnicity: Black or African American Age: 29 Sex: F
SUBJECTIVE (must complete this section)
CC: "I have been experiencing vaginal spotting and pelvic pain"
HPI: The patient is 29-year-old Black American female who presents to the clinic with unilateral pelvic pain and light
vaginal spotting. She is 6 weeks pregnant and has tested positive for pregnancy. She has a previous history of one
episode of pelvic inflammatory disease. When asked about the nature of the pain, she describes it as mild and on one
side of the abdomen. She does not remember exactly how the pain started since she thought it was because of the
pregnancy but she got alarmed when she started experiencing vaginal spotting, thus the reason for seeking medical
attention. At the time of the visit, she had not taken any medications for the pain.
Medications:The patient states that she occasionally takes pain relievers during her menstrual cycle. However, since she
realized she was pregnant, she has not taken any medications.
Previous Medical History: The patient has a previous history of one episode of pelvic inflammatory disease.
Allergies:The patient does not have any allergies.
Medication Intolerances: Patient is not aware of any medical intolerance.
Chronic Illnesses/Major traumas: The patient does not have a history of traumas or chronic diseases.
Hospitalizations/Surgeries:The patient does not have any history of surgeries or major hospitalizations.
FAMILY HISTORY (must complete this section)
M:Alive with a history of back pain. MGM:
Alive with a history of hypertension MGF:
Deceased with no medical records.
F:Alive with arthritis.
PGM:Alive and diabetic.
PGF:Alive with no clear medical history on record.
Social History:The patient is a recent graduate middle school teacher. She is currently teaching at a private middle
school near home. She lives with her both parents who have a home in the sub-urban neighborhood. She two siblings,
an elder sister who is currently married and a young brother who is still in college. She spends weekdays teaching at
the school and on weekends, she is either at home with parents or out with friends. Unfortunately, she stopped going
out for parties when she got pregnant. She states for four weeks now since she realized she was pregnant, she has not
been able to go out, only spends time with her boyfriend at a local restaurant. She is a non-smoker and was drinking
alcohol until she got pregnant.
REVIEW OF SYSTEMS (must complete this section)
General:The patient appears to be a well-developed and Cardiovascular: Patient denies chest pain, or
nourished 29-year-old female. She presents mild distress palpitations. She denies murmurs. Denies activity
due to the pain discomfort. intolerance.
Skin: Patient has a smooth skin. She denies skin rashes, Respiratory: Patient denies dry or productive cough.
scaring or lesions on any part of the skin. She denies skin Denies shortness of breath or dyspnea. Denies
itching or hair loss. abnormal breathing effort.
Assessment, Plan Verified Study Solutions
CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Wisline Dorvil Course: NSG6430
Patient Name: (Initials ONLY) J. C Date:3/20/2025 Time: 9. AM
Ethnicity: Black or African American Age: 29 Sex: F
SUBJECTIVE (must complete this section)
CC: "I have been experiencing vaginal spotting and pelvic pain"
HPI: The patient is 29-year-old Black American female who presents to the clinic with unilateral pelvic pain and light
vaginal spotting. She is 6 weeks pregnant and has tested positive for pregnancy. She has a previous history of one
episode of pelvic inflammatory disease. When asked about the nature of the pain, she describes it as mild and on one
side of the abdomen. She does not remember exactly how the pain started since she thought it was because of the
pregnancy but she got alarmed when she started experiencing vaginal spotting, thus the reason for seeking medical
attention. At the time of the visit, she had not taken any medications for the pain.
Medications:The patient states that she occasionally takes pain relievers during her menstrual cycle. However, since she
realized she was pregnant, she has not taken any medications.
Previous Medical History: The patient has a previous history of one episode of pelvic inflammatory disease.
Allergies:The patient does not have any allergies.
Medication Intolerances: Patient is not aware of any medical intolerance.
Chronic Illnesses/Major traumas: The patient does not have a history of traumas or chronic diseases.
Hospitalizations/Surgeries:The patient does not have any history of surgeries or major hospitalizations.
FAMILY HISTORY (must complete this section)
M:Alive with a history of back pain. MGM:
Alive with a history of hypertension MGF:
Deceased with no medical records.
F:Alive with arthritis.
PGM:Alive and diabetic.
PGF:Alive with no clear medical history on record.
Social History:The patient is a recent graduate middle school teacher. She is currently teaching at a private middle
school near home. She lives with her both parents who have a home in the sub-urban neighborhood. She two siblings,
an elder sister who is currently married and a young brother who is still in college. She spends weekdays teaching at
the school and on weekends, she is either at home with parents or out with friends. Unfortunately, she stopped going
out for parties when she got pregnant. She states for four weeks now since she realized she was pregnant, she has not
been able to go out, only spends time with her boyfriend at a local restaurant. She is a non-smoker and was drinking
alcohol until she got pregnant.
REVIEW OF SYSTEMS (must complete this section)
General:The patient appears to be a well-developed and Cardiovascular: Patient denies chest pain, or
nourished 29-year-old female. She presents mild distress palpitations. She denies murmurs. Denies activity
due to the pain discomfort. intolerance.
Skin: Patient has a smooth skin. She denies skin rashes, Respiratory: Patient denies dry or productive cough.
scaring or lesions on any part of the skin. She denies skin Denies shortness of breath or dyspnea. Denies
itching or hair loss. abnormal breathing effort.
