SOAP NOTE
Women’s Health / Primary Care SOAP Age Range: 25- 30 Gender: Female Occupation: Receptionist Subjective: ID: M.L.
Reliability: Patient is a knowledgeable and a reliable source of information.
Reason for seeking Care (CC): Complaint of heaviness and pain in the left breast on and off since the last 4 months. History of Present Illness: Not applicable. No history of change in surgical, medical or family history.
Travel History past 30 days: No history of travelling in the last 30 days.
Current Medications: Denies being on any medication currently or in the past. Allergies (Medication, Food, Environmental): Not allergic to any medication, food or environmental influences. Immunizations: Received all the immunizations in a timely manner. History of Present Illness: The patient was ...
