*NURSING > iHuman Case Studies > Carolyn Cross iHuman SOAP NOTE | iHuman SOAP NOTE (All)
Carolyn Cross iHuman SOAP NOTE | iHuman SOAP NOTE
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Week 7 iHuman SOAP NOTE Carolyn Cross SOAP NOTE Name: CC Date: 4/17/18 Time: 6:16pm Age: 41 Sex: F SUBJECTIVE CC: “I’m here today for a wellness visit.” Patient came in for a health ch ... eck-up. She Voiced her concern for breast cancer due to her family history. HPI: Patient denies any current or past medical problems. Medications: Vitamin E for Cystic breast disease Aspirin or Tylenol for HA PMH Allergies: NA Medication Intolerances: NA Chronic Illnesses/Major traumas: NA Hospitalizations/Surgeries: 2 child births and bilateral tubal ligation after 2nd pregnancy at the age of 35. Family History Father: hypertension, hyperlipidemia Mother: Hx of type 2 diabetes Brothers: healthy and very physically active Social History Ethnicity: Hispanic-American Occupation: Middle-school learning specialist Marital status: married x ~14 years Children: 2 sons (6 and 8) Tobacco: never Recreational drugs: never Alcohol: wine (one glass at dinner most days) Enjoy cooking, gardening, and reading - - - - - - - Continued [Show More]
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