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NSG 6020 Soap Note – Herpes Simplex Virus
NSG 6020 Soap Note – Herpes Simplex Virus
SOAP NOTE
| Name: Patient | 4/19 | Time: 9:00 am | ||
| Age: 29 | Sex: Female | |||
| SUBJECTIVE | ||||
| CC:
“My rash is back on my private area”. |
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| HPI:
Ms. Lawrence is 29 year old female patient presenting to the office today with a rash on her vagina. She had an office visit in May and June. She was prescribed acyclovir TID x10 days. She stated the medication helped for a while and now the “rash” is back. Lesions were cultured and negative for HSV-2 during her last visit. She presents today with reoccurring symptoms. She denies any fever, myalgia, or malaise. NSG 6020 Soap Note – Herpes Simplex Virus. |
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| Medications:
None |
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| PMH
Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas None Chronic Health Problems:
Hospitalizations/Surgeries none Other: Immunizations: Unknown Environmental hazards: Denies any environmental hazards. Able to perform ADLs without difficulty. Safety measures: Not discussed Exercise and leisure: She is active and goes to the gym daily. Sleep: Tries to get at least 6 hours of sleep every night. Diet: Eats healthy meals. |
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| Family History
Did not provide information |
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| Social History
Denies drinking. Denies smoking. Denies illicit drugs. |
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| ROS | ||||
| General
Denies fatigue. Denies fever, night sweats or recent weight gain or loss. |
Cardiovascular
Denies chest pain. No murmur, bruits, palpitations, or edema. |
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| Skin
Genital lesions present. Itching present to vaginal area. |
Respiratory
Denies cough. Denies hemoptysis, wheezing, or exposure to TB. Denies SOB. |
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| Eyes
Denies complaints of blurred vision or visual disturbances reported. |
Gastrointestinal
Denies abdominal pain, nausea, vomiting, dysphagia or abnormal stools. |
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| Ears
Denies hearing loss discharge or ear pain. |
Genitourinary/Gynecological
Denies any frequency, hesitancy, nocturia or urgency. |
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| Nose/Mouth/Throat
Denies dryness, hoarseness, or mouth pain. |
Musculoskeletal
Denies pain. |
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| Breast
Denies any lumps or bumps. |
Neurological
Denies syncope or headache, focal weakness, numbness, paresthesia’s, tremors, gait instability, falls or memory loss. |
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| Heme/Lymph/Endo: Denies easy bruising, bleeding, or blood clots. Denies increased hunger or thirst. Denies recent weight loss. Denise night sweats or swollen glands. | Psychiatric
Denies any anxiety or suicidal ideations |
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| OBJECTIVE | ||||
| Weight 132 lbs BMI 21.3 | Temp 98.6 | BP 114/68 | ||
| Height 5’6” | Pulse 71 | Resp 16 | ||
| General Appearance
This is a pleasant 29 year old African American female that presents with concern about recurring lesions. |
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| Skin
No cyanosis or clubbing noted. Skin is warm, dry and intact. |
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| HEENT
Head: Head is normocephalic, no tenderness during palpation. Eyes: PERRLA (3 mm) Ears: External auditory canals clear. Tympanic membranes intact, pearly gray with light reflex noted. Nose: Nasal mucosa moist without drainage, septum midline. Neck: Supple. Full ROM. No lymphadenopathy; no occipital nodes. No thyromegaly or nodules or masses palpated. Oral mucosa pink and moist. Trachea midline. NSG 6020 Soap Note – Herpes Simplex Virus. |
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| Cardiovascular
Sinus rhythm, S1 and S2. No S3, S4, rubs, clicks or murmurs noted. No thrills, heaves or lifts with palpation. Capillary refill 2 seconds. Pulses 3+ throughout. No edema noted. |
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| Respiratory
Respirations regular, even and unlabored. Chest expansion is symmetrical. No crackles auscultated. Lungs clear bilaterally and diminished to the bases. No tactile fremitus. |
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| Gastrointestinal
Abdomen soft. BS+ in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. |
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| Breast
Breasts are free from masses or tenderness. No discharge, no dimpling, wrinkling or discoloration noted. |
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…
NSG 6020 Week 5 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
Week 6 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
Week 6 Physical Exam Video and Write Up Assignment
Complete Health History and Physical Assessment Write-Up Presentation
This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment.
Week 7 SOAP Note Assignment
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
ORDER NOW FOR CUSTOM-WRITTEN SOLUTIONS
Week 8 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.
Week 9 SOAP Note Assignment
SOAP NOTE
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.
Include the reference number from CORE in your document.
Submit your document to the Submissions Area by the due date assigned.