Using the attached SOAP note template, create one. Be creative, it has to be an adult patient this is the only requirement. Every other requirement is stated in the template.
There is also attached a completed SOAP note from another student so you can see how its done.
To do this paperwork you need to know how and what is a SOAP note.
Name: Pt. Encounter Number:
Date: Age: Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other
related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with:
lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, and marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,
and energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, and
edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, and any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, and TB
Eyes
Corrective lenses, blurring, and visual changes of
any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, and black,
tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and throat
pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture
hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, and black-out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, and cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, and previous dx
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first and then brighter later.
Skin
Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive
light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two
seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
Genitourinary
Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.
A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink
and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.
No adnexal masses or tenderness. Ovaries are nonpalpable.
(Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)
(Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is
smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm).
Musculoskeletal
Full ROM seen in all four extremities as the patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though
clear and of normal rate and cadence; answers questions appropriately.
Urinalysis—pending
Urine culture—pending
Wet prep—pending
Special Tests
Diagnosis
o Include at least three differential diagnosis
o Final diagnosis
Evidence for final diagnosis should be documented in your Subjective and
Objective exams.
PLAN including education
o Plan:
Further testing
Medication
Education
Nonmedication treatments
Follow-up
Name:LC |
Pt. Encounter Number: |
|
Date: 08/30/2019 |
Age: 35 |
Sex: Female |
SUBJECTIVE |
||
CC: ” I have been bleeding between my periods.” |
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HPI: 35-years-old, female patient went to the clinic today worried about spotting between her menstrual cycles. This has been going on for about 3 months, and there are no apparent patterns to when the spotting happens. she does, however, mention that she thinks it is worse after she has intercourse. Her menstrual cycles occur regularly in 28-day intervals and last three to four days. Patient denies any history of STD and states she used condom as a contraceptive method and for protection. She is monogamous with her partner of eight years. Her last pap smears were a year ago showing negative results. |
||
Medications: N/A |
||
PMH Allergies: Not Known Drug Allergies. Medication Intolerances: None Chronic Illnesses/Major traumas: N/A Hospitalizations/Surgeries: negative |
||
Family History Pt’s mother is alive and has history of Hypertension and hyperlipidemia. Father suffers from COPD and her two siblings are alive and healthy. |
||
Social History Patient is heterosexual, has a monogamous relationship for the past eight years. Pt only drinks one or two cups of alcoholic beverages in important events, she use to drink coffee three times a day and denies smoking and drugs. |
||
ROS |
||
General Good appearance, denies fatigue, fever and malaise. |
Cardiovascular Patient denies chest pain, palpitations, or history of heart murmur |
|
Skin Negative for skin rashes, delayed healing, bruising, or skin discoloration. |
Respiratory No presence of cough, wheezing, negative history of pneumonia |
|
Eyes No visual changes, blurred vision, or double vision. |
Gastrointestinal No complaints of abdominal pain, eating disorders, ulcers, constipation, or diarrhea |
|
Ears Denies ear pain, abnormal discharge, or tinnitus |
Genitourinary/Gynecological Patient denies frequency, burning or pain with urination. She also refutes history of sexually transmitted diseases. Last Pap exam 1 years ago with unremarkable result at this time. Patient refers spotting between her menstrual cycles. GH: G2, Para 1, T1, A1, P0, L1. |
|
Nose/Mouth/Throat Denies sore throat, nose bleeds, sinus problems, or dental disease |
Musculoskeletal Negative for joint pain, neck stiffness, or back pain. |
|
Breast Denies presence of tumors , skin changes and nipple discharge. |
Neurological Denies history of seizures, transient paralysis, syncope, or black out spells |
|
Heme/Lymph/Endo No presence of swollen lymph nodes. Denies changes in appetite or heat/cold intolerance. |
Psychiatric Negative for depression, anxiety, or suicidal ideation |
|
OBJECTIVE |
||
Weight: 163 pounds BMI:27.98 |
Temp: 96.4F |
BP: 138/67 |
Height: 5’4’ |
Pulse: 74 |
Resp: 18 |
General Appearance Well-developed and nourished in no distress. Pt has good appearance and maintain eye contact during the conversation. Overweight |
||
Skin: no rashes, good turgor, RUE mid skin thickness, shiny, no erythema present. |
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HEENT Head is norm cephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is non-erythematous and without exudate. Teeth are in good repair. |
||
Cardiovascular
Rate and rhythm are regular. No murmurs or gallops present. |
||
Respiratory
Clear to auscultation bilaterally, No SOB, wheezes, crackles, or rales . |
||
Gastrointestinal
Abdomen is soft, non-tender, and obese. Bowel sounds present in all quadrants |
||
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. |
||
Genitourinary Bladder is non-distended; no CVA tenderness. Patient deferred rectal exam. |
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Musculoskeletal
Symmetric, no presence of deformities. Peripheral pulses are normal and present. |
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Neurological Balance stable, gait normal, posture erect, speech clear |
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Psychiatric
A&O ×3, answers questions appropriately and maintains appropriate eye contact during the assessment |
||
Lab Tests: CBC-BMP- (WNL). Urinalysis done in office -Negative result. Special procedures: Pap smears done- send to lab. |
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Special Test .N/A |
||
Diagnosis |
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Differential Diagnosis ICD-10(N87.9): Micro-glandular Hyperplasia of the uterine cervix is characterized for a lesion in the endocervical mucosa often present in woman’s with history of contraceptives or pregnancy. And has a benign etiology. ICD-10(R87.810) Squamous papilloma: is a benign solid tumor typically located on the ectocervix, it arises most commonly as a result of inflammation or trauma, grossly, the tumor is usually small, measuring 2-5 mm in diameter, this resembles a typical condyloma acuminate. The diagnosis is done by biopsy and is not applied to this patient. (Milner D, Danny A .2015) ICD-10(D25.9) Leiomyomas: This benign neoplasm may originate in the cervix and account for approximately 8% of all uterine smooth muscle tumors, they are similar to tumors in the fundus, when located in the cervix, they usually are small like 5-10 mm in diameter, symptoms depend on size and location, and consist in excessive menstrual bleeding (menorrhagia, often cause anemia and may lead to infertility. the diagnosis is done by biopsy, so you cannot rule out completely until you have your result. ICD-10(N80.9)- Endometriosis: When present in the cervix is usually an incidental finding, however, it may present as a mass or abnormal bleeding, particularly postcoital, grossly, it may appear as bluish -red or bluish- black lesion, typically 1-3 mm in diameter, symptoms may include pelvic pain that worsen during menstruation, painful intercourse, painful bowel movement or urination, infertility, the diagnosis is done by biopsy, so you cannot rule out completely until you have your result. Final diagnosis: ICD-10 (N84.1) Polyp of Cervix Uteri: Characterized as a common benign tumor lesion on the surface of the cervical canal, that can produce irregular menstrual bleeding and course asymptomatic. The most frequent symptom is intermenstrual bleeding as is refer for the patient. In another’s woman can be diagnosed due the abnormally heavy menstrual bleeding, vaginal bleeding in post-menopausal women, bleeding after sex and leukorrhea, diagnosis is done at pelvic examination show a red or purple projection from the cervical canal ,diagnosis is confirmed by a cervical biopsy which will reveal the nature of the cell present, In this case the Diagnosis of Polyp of Cervix Uteri is rule in by the positives data finding at physical exam and Biopsy is order for confirm the diagnosis.(Smith, Melanie M,2016) |
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PLAN including education Patient will be scheduled for elective excision of the polyp. Pt will be referral to Gynecologist for the procedure. |
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· Education Patient education and supportive counseling was critical during this encounter. First, the practitioner discussed with the patient the nature of her condition including the symptoms, pathophysiology, and characteristics of treatment. The patient was educated about that treatment consists of simple removal of the polyp and prognosis is generally good. Also patient was informed that around 1% of cervical polyps will show neoplastic change which may lead to cancer, the cause is uncertain, but they are often associated with inflammation of the cervix, they may also occur as a result of raised levels of estrogens or clogged cervical blood vessel Patient encourage to continue having protective sexual intercourse, and to perform her pap smears yearly. Follow-up The practitioner will schedule a follow-up appointment after polys removed and biopsy result obtained. |
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References
Smith J, Melanie M, (2013-05-10).
” Cervical Polys”. Medline, Retrieved 2016-11-05.
Taube ET, Frangini S, Caselitz J, Chiantera V (.2013).
Cervicitis in a woman associated with an atypical form of microglandular
hyperplasia: a case report and review of literature. Int J Gynecol Pathol. May: 32(3):329-34. [medicine]
Milner D, Danny A. (2015). Diagnostic Pathology: “The link between HPV and Cancer”.CD. September 30. 2015.Retreived 11 August 2016.
Cervical endometriosis: a diagnostic and management dilemma.Arch Gynecol Obstet.Oct 2015.272:289-93.[Medicine]
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