-
- QUESTION
This week, you will submit a SOAP note.
Select a “patient” (friend or family member) on whom to perform a complete H&P.
NOTE: DO NOT USE REAL NAMES OR INITIALS OR OTHERWISE IDENTIFY YOUR “PATIENT.” FAILURE TO MAINTAIN PRIVACY WILL RESULT IN A FAILING SCORE.
Using the format specified below, write a 1 to 2-page SOAP note on your “patient.” The HPI should be presented in a paragraph, and the rest of the data including the ROS should be presented in a list format.
Collect only the information that is pertinent to the chief complaint of the patient to include in your SOAP note. Aim for a single page using normal margins and format.
The SOAP Note must contain all required elements as outlined in the rubric below.
You must self-score your SOAP note using the rubric
| Subject | Nursing | Pages | 4 | Style | APA |
|---|
Answer
Soap Note
SUBJECTIVE DATA
Age: 54 Race: African American Sex: Female Date: 3/16/2019 Time: 8:45 Am
Occupation: Accountant Language: English
CC: Light bleeding and pain.
History of Present Illness (HPI): Patient presents to the clinic for medical checkup for light bleeding and pain. The symptoms onset was 4 days ago. The location is a lower part of the abdomen. Symptoms have been persistent for four days. The characteristics are light bleeding and pain. Patient denies any aggravating factors. The pain reduces when she lays down. She has taken Ibuprofen for pain.
Medication: Ibuprofen (400 mg) twice a day for the pain.
PMH:
Allergies: Red meat and. Medical Intolerance: Patient denies. Chronic Illnesses: Patient denies. Hospitalization: 1 week at the age of 24 after a car accident. Surgery: Caesarian section at the age of 29.
Family History: Patient is married with one child (25 years). Lives with the husband. Both parents are deceased. Father died from a car accident at 72 years and mother died from hypertension at 68 years.
Social History: Patient is an accountant. She is a Roman Catholic and engages in community services. Patient denies taking alcohol or any illegal substance. The patient has maintained a healthy lifestyle.
ROS
General: Patient denies fever, chills, weight changes, and night sweats.
Skin: Denies rashes. Notes one CS scar. Denies lesions, moles, and discolorations.
Eyes: Denies blurring, visual changes, and use of corrective lenses.
Ears: Patient denies ringing in the ears, pain, or hearing loss.
Nose/Mouth/Throat: Patient denies sinuses, throat pain, and nose bleeds.
Breast: Patient denies lumps and bumps
Cardiovascular: Patient denies chest pains, palpations, and PND
Respiratory: Patient denies dyspnea, pneumonia history, and TB
Gastrointestinal: Patient denies eating disorders, constipation, and changes in stool.
Genitourinary/Gynecological: Patient notes pain and light bleeding. She rates the pain as 5 on a 1-10 rate. She denies color changes in the urine. Last menstrual was at 47 years. Patient denies painful urination. Last pap smear was 2 years ago.
Musculoskeletal: Patient denies joint or back pain. She also denies swelling of joints.
Neurological: Patient denies paresthesia, blackout spells, and seizures.
Heme/Endo/Lymph: Patient confirms HIV negative two months ago. She denies blood transfusion history, and heat intolerance. She also denies excess thirst and hunger.
Psychiatric: Patient denies depression, insomnia, suicidal ideation, and anxiety.
OBJECTIVE DATA
Weight: 162 lbs. BMI: 27.0 Temp: 98.2 BP: 129/75 Height: 5’ 5’’
Pulse: 94 Resp: 24
General Appearance: Patient is African American and is oriented to the surrounding. She is responsive and shows a high level of hygiene. She shows no sign of acute distress and confusion. She responds to all questions appropriately.
Skin: Skin is dry, warm, and smooth. No acne, colorations, or lesions.
HEENT: Head is normocephalic and has no lesions. The patient has evenly distributed hair. Eyes have no cataracts, conjunctiva or lesions. Ears: Positive light reflex, pearly grey TMs, and patent canals. Nose: Nasal mucosa is pink. The neck is supple and has no lesions or masses. Mouth: Oral mucosa is moist and pink. There are no dental carries or sore throat.
Cardiovascular: S1, S1 have regular rates. No grit nor murmurs. Capillary refill is 1.5 seconds.
Respiratory: Symmetrical chest wall. Clear lungs and bilateral auscultation.
Gastrointestinal: Normal abdominal tests. Active BS in all quadrants and waist circumference is normal.
Breasts: No lesions, masses, or lumps. No discharge, dimpling, or wrinkling.
Genitourinary: Light bleeding is confirmed. No palpable masses. The uterus is small in size. The vulva is atrophic and thin. Vaginal walls are pink and well rugate. The cervix is pink. No lesions.
Musculoskeletal: ROM is full in all extremities demonstrated in the patient’s movement.
Neurological: Normal gait and balance, good tone, erect posture, and clear speech.
Psychiatric: the patient is oriented and alert. The patient is clean and wears decent clothes. Her speech is soft and clear.
Lab Tests: Regular abdominal tests. Biopsy for the endometrium shows no tenderness and atrophic endometrium.
Diagnosis
Primary Diagnosis: Atrophic Vaginitis. Described by thinning of vaginal walls due to low estrogen in the body. The condition usually occurs after menopause (Lee et al., 2018).
Differential Diagnosis
Cervical Polyp: Disease is caused by growths and masses in the inner walls of the uterus. The polyps originate from overgrowths in the lining (Levy et al., 2016). It is common among women who are in their menopause.
Endometrial Hyperplasia: It is a form of cancer that affects the uterus. It is characterized by vaginal bleeding (Sanderson et al., 2017). It is caused by hormonal imbalance.
Plan
Advanced Testing: Hysteroscopy exam
Medication: Daily topical estrogen for the first three weeks. Twice for preservation.
Education: Adherence to the estrogen dosage. The patient is sexually active thus should be aroused before intercourse
Non-medication treatment: Use Replens as OTC moisturizer during sexual intercourse.
Follow-up: Return to the clinic in case of any complications.
Health Maintenance: Avoid vaginal dryness.
References
|
Lee, A., Kim, T. H., Lee, H. H., Kim, Y. S., Enkhbold, T., Lee, B., ... & Song, K. (2018). Therapeutic Approaches to Atrophic Vaginitis in Postmenopausal Women: A Systematic Review with a Network Meta-analysis of Randomized Controlled Trials. Journal of menopausal medicine, 24(1), 1-10. Levy, R. A., Kumarapeli, A. R., Spencer, H. J., & Quick, C. M. (2016). Cervical polyps: Is histologic evaluation necessary? Pathology-Research and Practice, 212(9), 800-803. Sanderson, P. A., Critchley, H. O., Williams, A. R., Arends, M. J., & Saunders, P. T. (2017). New concepts for an old problem: the diagnosis of endometrial hyperplasia. Human reproduction update, 23(2), 232-254.
Appendix
|
|