SOAP Observe 1
Maria Rodriguez
Age: 25 y.o.
Ethnicity: Hispanic (the best nursing writing service, a studybay for your papers)
Previous Medical historical past: None
Previous Surgical Historical past: Tonsillectomy age 7
Drugs: none
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Household historical past: Mom Diabetes, Father Hyperlipidemia
Employment: works as a phlebotomist full time
S: Maria is a longtime affected person who presents to workplace at present for contraception. Pt is in a monogamous relationship along with her present boyfriend of Four months and is utilizing condoms 100% of the time. Pt wish to begin a extra dependable type of contraception. Menarche 12 y.o menses: each 28 days and lasts for five days, affected person denies cramps or irregular menses historical past. Affected person is a non-smoker and doesn’t use any substances. Final pap was 6 months in the past destructive for cytology. Gonorrhea and Chlamydia tradition 6 months in the past was neg/neg. HPV vaccine accomplished.
O: 5 ft 6 inches 140 kilos 98.Four-80-16-122/76
Common: Wholesome showing Hispanic (the best nursing writing service, a studybay for your papers) girl in no obvious misery
Pores and skin: No pores and skin lesions recognized
Head: Normocephalic, good hair distribution, no alopecia no nits
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Eyes: Symmetrical with no erythema or discharge. Imaginative and prescient grossly regular
Ears: Symmetrical with gross listening to intact
Nostril: midline, no septal defect, no discharge
Mouth: good dentition, moist mucous membranes
Cardiac: HR 80 regular sinuses rhythm, no S3 or S4, no arrhythmias famous
Lungs: Clear to auscultation bilaterally A & P, no use of accent muscle groups
Stomach: flat, comfortable, non-distended. Bowel sounds energetic in all Four quadrants, tympanic all through, no hepatosplenomegaly, no rebound or guarding.
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A: Contraception Counseling
P: Diagnostics updated
Schooling: Throughout the 20-minute face-to-face go to, I mentioned with affected person the assorted types of contraception together with barrier, hormonal, non-hormonal, abstinence and pure household planning. Mentioned efficacy, value, dangers and advantages of every methodology, utilizing the Contraception possibility handout. Mentioned timing to start out methodology and how one can use methodology to make sure efficacy. Affected person determined to start out oral contraceptives. Mentioned Sunday begin, every day dosing, missed drugs, widespread facet impact and main unwanted side effects, resembling ACHES and when to name.
Proceed Condom use for STD prevention
Pharm: Ortho-Tricyclen 28 day, 1 tablet each day to start out on Sunday after first day of menses. three refills
Referrals: none
Observe- up: three months
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