NURSING 491 (NURSING 491)

“My cycles are so erratic and irregular.” HPI: AA is a 19 year old, Hispanic female who presents for her first gynecological exam with complaints of irregular periods. Pt. has no previous medical hx. Pt. reports LMP was two weeks ago. Reports she only has 2-3 periods a year on average since beginning her cycles at 16 years old. Her cycles generally consist of 2-3 days of moderate bleeding in which one tampon last a few hours, followed by 1-2 days of light bleeding and spotting. Pt. re...

Module 3: Orlando Case Study & Nursing in the 50’s and 60’s

HPI: Patient brought in today by his mother for a complaint of fever and rash. The fever began 3 days ago and is of normal levels in the morning then gets as high as 103 to 104 degrees in the afternoons. Mother reported that patient has also had clear rhinorrhea and in the last 24 hours he has developed a red, diffuse rash to the torso and abdomen that does not itch and a dry cough in the last day. Mother reports he is drinking, but not as well as usual. He did have a good wet diaper this ...

SUBJECTIVE DATA (S): IDENTIFYING DATA: Initials: J.S . Age: 10 years Race: Caucasian Gender: M ale Patient is accompanied by his mother who is the informant. CHIEF COMPLAINT (CC): Mother states that the p atient complains of “ sore throat and fever for 3 days .” HISTORY OF PRESENT ILLNESS (H PI): Patient c/o sore throat and fever for 3 days. Patient states that his throat hurts really bad when he swallows and his throat feels raw. Mother states that his temperature las...

Women’s Health Mini SOAP Notes ICD 10: N39.0 S: Burning and pain with urination for 3 three days. Stated that her urine looks cloudy and has a foul odor. Denies fever, nausea, vomiting, myalgia, flank pain, blood in urine, any vaginal discharge, and, vaginal/vulvar irritation. She is sexually active, has same partner for last 4 years. G1P1001, with normal vaginal delivery. Menarche age 11. Last menses one week ago; regular 4- 5 days. Tested for STD one year ago. Negative for Chlamydia an...

F_Escobar_N491_M3|Module 3: Orlando Case Study & Nursing in the 50’s and 60’s

TA is a 26-month-old male with Down syndrome who has presented with his mother’s statement of “a tummy ache”. Mother has also noted that TA has been lethargic, whining and has a poor appetite for the last two days. She continues on stating that TA fell out of this bed while taking a nap. TA appears listless and pale during examination. TA has a history of atrioventricular septal defect (complete), status-post surgical repair; congestive heart failure, resolved following surgery; and, globa...

TA is a 26-month-old male with Down syndrome who has presented with his mother’s statement of “a tummy ache”. Mother has also noted that TA has been lethargic, whining and has a poor appetite for the last two days. She continues on stating that TA fell out of this bed while taking a nap. TA appears listless and pale during examination. TA has a history of atrioventricular septal defect (complete), status-post surgical repair; congestive heart failure, resolved following surgery; and, globa...

WOMEN’S HEALTH MINI SOAP NOTES