SOAP Note week 6

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.

Don't use plagiarized sources. Get Your Custom Essay on
SOAP Note week 6
Just from $13/Page
Order Essay

To do this paperwork you need to know how and what is a SOAP note.

Name: Pt. Encounter Number:

Date: Age: Sex:


Reason given by the patient for seeking medical care “in quotes”

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 )



Medication Intolerances:

Chronic Illnesses/Major traumas


“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



Weight change, fatigue, fever, chills, night sweats,

and energy level


Chest pain, palpitations, PND, orthopnea, and



Delayed healing, rashes, bruising, bleeding or skin

discolorations, and any changes in lesions or moles


Cough, wheezing, hemoptysis, dyspnea, pneumonia

hx, and TB


Corrective lenses, blurring, and visual changes of

any kind


Abdominal pain, N/V/D, constipation, hepatitis,

hemorrhoids, eating disorders, ulcers, and black,

tarry stools

Ear pain, hearing loss, ringing in ears, and


Urgency, frequency burning, change in color of


Contraception, sexual activity, STDs

Female: last pap, breast, mammo, menstrual

complaints, vaginal discharge, pregnancy hx

Male: prostate, PSA, urinary complaints

Sinus problems, dysphagia, nose bleeds or

discharge, dental disease, hoarseness, and throat


Back pain, joint swelling, stiffness or pain, fracture

hx, and osteoporosis

SBE, lumps, bumps, or changes

Syncope, seizures, transient paralysis, weakness,

paresthesias, and black-out spells


HIV status, bruising, blood transfusion hx, night

sweats, swollen glands, increase thirst, increase

hunger, and cold or heat intolerance


Depression, anxiety, sleeping difficulties, suicidal

ideation/attempts, and previous dx


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 is brown, warm, dry, clean, and intact. No rashes or lesions noted.

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.


S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two

seconds. Pulses 3+ throughout. No edema.

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.


Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.


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).

Full ROM seen in all four extremities as the patient moved about the exam room.


Speech clear. Good tone. Posture erect. Balance stable; gait normal.

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.

Lab Tests


Urine culture—pending

Wet prep—pending

Special Tests


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


 Pt. Encounter Number:

Date: 08/30/2019

Age: 35

Sex: Female



 ” I have been bleeding between my periods.”

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


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.



Good appearance, denies fatigue, fever and malaise.


Patient denies chest pain, palpitations, or history of heart murmur


Negative for skin rashes, delayed healing, bruising, or skin discoloration.


No presence of cough, wheezing, negative history of pneumonia


No visual changes, blurred vision, or double vision.


No complaints of abdominal pain, eating disorders, ulcers, constipation, or diarrhea


Denies ear pain, abnormal discharge, or tinnitus


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.


Denies sore throat, nose bleeds, sinus problems, or dental disease


Negative for joint pain, neck stiffness, or back pain.


Denies presence of tumors , skin changes and nipple discharge.


Denies history of seizures, transient paralysis, syncope, or black out spells


No presence of swollen lymph nodes. Denies changes in appetite or heat/cold intolerance.


Negative for depression, anxiety, or suicidal ideation


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.


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.


Rate and rhythm are regular. No murmurs or gallops present.


Clear to auscultation bilaterally, No SOB, wheezes, crackles, or rales .


Abdomen is soft, non-tender, and obese. Bowel sounds present in all quadrants


Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.


Bladder is non-distended; no CVA tenderness. Patient deferred rectal exam. 
External genitalia: Unremarkable. Speculum examination: Reveals a cherry- red growth extending from the internal cervix into vaginal canal. On bimanual examination, it is appreciated as a mobile mass of approximately 1 cm of diameter.


Symmetric, no presence of deformities. Peripheral pulses are normal and present.


Balance stable, gait normal, posture erect, speech clear


A&O ×3, answers questions appropriately and maintains appropriate eye contact during the assessment

Lab Tests:


Urinalysis done in office -Negative result.

Special procedures: Pap smears done- send to lab.

Special Test



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)

PLAN including education

Patient will be scheduled for elective excision of the polyp.

Pt will be referral to Gynecologist for the procedure.

· 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.


The practitioner will schedule a follow-up appointment after polys removed

and biopsy result obtained.


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]

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.


Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.


Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

  • Most Qualified Writer $10FREE
  • Plagiarism Scan Report $10FREE
  • Unlimited Revisions $08FREE
  • Paper Formatting $05FREE
  • Cover Page $05FREE
  • Referencing & Bibliography $10FREE
  • Dedicated User Area $08FREE
  • 24/7 Order Tracking $05FREE
  • Periodic Email Alerts $05FREE

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

  • On-time Delivery
  • 24/7 Order Tracking
  • Access to Authentic Sources
Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.


Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

All samples
Essay (any type)
Essay (any type)
The Value of a Nursing Degree
Undergrad. (yrs 3-4)
View this sample

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.


Happy Clients


Words Written This Week


Ongoing Orders


Customer Satisfaction Rate

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

See How We Helped 9000+ Students Achieve Success


We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

  • Clear elicitation of your requirements.
  • Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

  • Proactive analysis of your writing.
  • Active communication to understand requirements.

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

  • Thorough research and analysis for every order.
  • Deliverance of reliable writing service to improve your grades.
Place an Order Start Chat Now

Order your essay today and save 30% with the discount code Happy