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Person has to be a nurse who understands nursing words and documents and soap notes.

needs to be plagiarism free and grammar and spelling corrected like american English not British English.

SOAP NOTE

Name:  WFDate: 04/16/2019Time: 1400
 Age: 27Sex: F
SUBJECTIVE
CC: “I am here for my papsmear” 
HPI: Patient is a 27 year old WF that presents for annual gynecologic exam, denies any problems at this time, states she uses Nexplanon for contraception and denies any problems with this contraception. Patient has no significant medical history. Last pap x 2 years ago.
Medications:Nexplanon Implant (Contraception)
PMHAllergies: NKDA Medication Intolerances: NONE Chronic Illnesses/Major traumasNone Hospitalizations/SurgeriesTonsillectomy- age 17Vaginal birth (twins) x 3 years ago
Family HistoryMother- Living with hypertensionFather-Living with Hypertension
Social HistoryLives with husband and twin daughters. Denies substance use/abuse, ETOH, tobacco, and marijuana use.
ROS
GeneralDenies weight change, fatigue, fever, chills, night sweats, energy level changes CardiovascularDenies chest pain, palpitations, PND, orthopnea, edema 
SkinDenies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles RespiratoryDenies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB 
EyesWears contacts, blurring, visual changes of any kind GastrointestinalDenies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools 
EarsDenies ear pain, hearing loss, ringing in ears, discharge Genitourinary/GynecologicalDenies urgency, frequency burning, change in color of urine.In monogamous relationship with husband for the past 5 years. Denies history of STDS.   Fe: last pap x 2 years ago, does not perform SBE.Denies menstrual complaints, vaginal discharge. 
Nose/Mouth/ThroatDenies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain MusculoskeletalDenies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis
BreastDenies SBE, lumps, bumps or changesNeurologicalDenies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/EndoDenies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerancePsychiatricDenies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
OBJECTIVE
Weight   180     BMI 29.1Temp 98.9BP 130/86
Height 5’6Pulse 78Resp 18
General AppearanceHealthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.
SkinSkin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENTHead is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
CardiovascularS1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
RespiratorySymmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
GastrointestinalAbdomen overweight; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. 
BreastBreast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
GenitourinaryBladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and multiparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are non-palpable.Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masse, sphincter tone is firmSpecimen collected and sent to lab for examination.Patient tolerated procedure well.
MusculoskeletalFull ROM seen in all 4 extremities as patient moved about the exam room.
NeurologicalSpeech clear. Good tone. Posture erect. Balance stable; gait normal.
PsychiatricAlert and oriented. Dressed in clean pants and shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab TestsWet prep – pendingPap Smear- Pending 
Special Tests N/A
 Diagnosis
 Differential Diagnoses and Rationale· 1- Screening for malignant neoplasm of cervixZ12.4: Encounter for screening for malignant neoplasm of cervixRationale: Patients that fall within this patient’s age range should have a pap smear to screen for cervical cancer every 5 years if most recent pap was noted to be normal (Schuiling & Likis, 2016).Diagnosiso 1- Screening for malignant neoplasm of cervixZ12.4: Encounter for screening for malignant neoplasm of cervixRationale: Patients that fall within this patient’s age range should have a pap smear to screen for cervical cancer every 5 years if most recent pap was noted to be normal (Schuiling & Likis, 2016).ReferenceSchuiling, K. D. & Likis, F. E. (2016). Women’s Gynecologic Health (3rd ed.). Sudbury, MA: Jones & Bartlett. Retrieved from: https://digitalbookshelf.southuniversity.edu/#/books/9781284124637/cfi/6/64!/4/2/6/26/12/6/4@0:0
Plan/Therapeutics
· Plan: · Further testing: No further testing currently. The need for further testing will be evaluated once the patient’s laboratory results are in.· MedicationNo medications at this time.· EducationPatient educated on performing SBE at home. Instructed that she will be called to go over lab results.Non-medication treatmentsInstructed to return to the office in one year for annual exam, or sooner, if needed.
 Evaluation of patient encounter ( PLEASE COMPLETE)

The patient presented for a routine medical examination. The patient’s most recent exam was noted to be WNL. I feel as though this exam went well. With the preceptor’s guidance it was decided that the patient’s contraception should be continued as she has been on this contraception without any problems.

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SOAP NOTE Name: WF Date:04/16/2019 Time: 1400 Age:27 Sex:F SUBJECTIVE CC: “I am here for my papsmear” HPI: Patient is a 27 year old WF that presents for annual gynecologic exam, denies any problems at this time, states she uses Nexplanon for contraception and denies any problems with this contraception. Patient has no significant medical history. Last pap x 2 years ago. Medications: Nexplanon Implant (Contraception) PMH Allergies: NKDA Medication Intolerances:NONE Chronic Illnesses/Major traumas None Hospitalizations/Surgeries Tonsillectomy- age 17 Vaginal birth (twins) x 3 years ago Family History Mother- Living with hypertension Father-Living with Hypertension Social History Lives with husband and twin daughters. Denies substance use/abuse, ETOH, tobacco, and marijuana use. ROS General Denies weight change, fatigue, fever, chills, night sweats, energy level changes Cardiovascular Denies chest pain, palpitations, PND, orthopnea, edema Skin Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory Denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB Eyes Wears contacts, blurring, visual changes of any kind Gastrointestinal Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears Denies ear pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Denies urgency, frequency burning, change in color of urine. In monogamous relationship withhusband for the past 5years. Denies history of STDS. Fe: last pap x 2 years ago, does not performSBE. Denies menstrual complaints, vaginal discharge. Nose/Mouth/Throat Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Musculoskeletal Denies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Breast Denies SBE, lumps, bumps or changes Neurological Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Heme/Lymph/Endo Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx OBJECTIVE Weight 180 BMI29.1 Temp98.9 BP130/86 Height 5’6 Pulse78 Resp18 General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. Skin Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen overweight; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink andmultiparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended

bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masse, sphincter tone is firm Specimen collected and sent to lab for examination. Patient tolerated procedure well. Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean pants and shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and

oriented. Dressed in clean pants and shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests Wet prep – pending Pap Smear- Pending Special Tests N/A Diagnosis Differential Diagnoses and Rationale o 1- Screening for malignant neoplasm of cervix Z12.4: Encounter for screening for malignant neoplasm of cervix Rationale: Patients that fall within this patient’s age range should have a pap smear to screen for cervical cancer every 5 years if most recent pap was noted to be normal (Schuiling&Likis, 2016). Diagnosis o 1- Screening for malignant neoplasm of cervix Z12.4: Encounter for screening for malignant neoplasm of cervix Rationale: Patients that fall within this patient’s age range should have a pap smear to screen for cervical cancer every 5 years if most recent pap was noted to be normal (Schuiling&Likis, 2016). Reference Schuiling, K. D. &Likis, F. E. (2016). Women’s Gynecologic Health (3rd ed.). Sudbury, MA: Jones & Bartlett. Retrieved from: https://digitalbookshelf.southuniversity.edu/#/books/9781284124637/cfi/6/64!/4/2/6/26/12/6/4@0:0 Plan/Therapeutics o Plan: � Further testing: No further testing currently. The need for further testing will be evaluated once the patient’s laboratory results are in. � Medication No medications at this time. � Education Patient educated on performing SBE at home. Instructed that she will be called to go over lab results. Non-medication treatments Instructed to return to the office in one year for annual exam, or sooner, if needed. Evaluation of patient encounter ( PLEASE COMPLETE) The patient presented for a routine medical examination. The patient’s most recent exam was noted to be WNL.I feel as though this exam went well. With the preceptor’s guidance it was decided that the patient’s contraception should be continued as she has been on this contraception without any problems. Patient Details Name: WF Age: 27 years Next of Kin: Husband Date: 16/20/19 Medical History The patient has no known drug allergies that would interfere with the contraception causing any side effects. No reported medical intolerances Has history of hypertension No current medications Significant surgical history of Tonsillectomy at the age of 17 years Weigh 180, BMI 29.1, lesser than 30 Social History No reported drug abuse

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SU_NSG6430_W4_A2_Pandey_ R.doc.docx

by Ram Pandey

Submission date: 10-Sep-2020 08:50PM (UTC-0400) Submission ID: 1384121034 File name: SU_NSG6430_W4_A2_Pandey_R.doc.docx (24.12K) Word count: 1327 Character count: 7714

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