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NSG6430 Week 3 SOAP Complete Latest Fall 23 Guide.
CONPH NSG6330/NSG6430 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Suleiny Saez Course: NSG6430
Patient Name: (Initials ONLY) EH Date: 8/31/23 Time: 9:30 am
Ethnicity: Latino Age: 28 years old Sex: Female
SUBJECTIVE (must complete this section)
CC: “I have been having pain and a burning sensation in my left breast.”
HPI:
The patient presented today to the clinic for evaluation of left breast pain. The patient had her first baby a month ago
and Sisucrugrerreinetly breastfeeding. The onset of symptoms was seven days ago. The patient reports pain is 4/10
in severity. EH reported having a 102F fever for the past three days, relieving malaise and chills with Ibuprofen 400mg.
The patient denies symptoms of weight loss or breast erythema but stated warmness and redness in the left breast.
Symptomatic treatment before arrival includes Tylenol/Ibuprofen.
Onset: 7 days
Location: left breast
Duration: 7 days
Characteristic: breast pain/ discomfort
Aggravating factor: breastfeeding
Relieving factors: warm compression, pumping
Severity: breast pain 4/10 on a pain scale of 0-10
Medications: Ibuprofen every 6 hours for pain
Previous Medical History:
Allergies: pollen
Medication Intolerances:
denies
Chronic Illnesses/Major traumas:
denies
Hospitalizations/Surgeries:
denies
T
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