KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT

ADULT, WOMEN, GERIATRICS

Student Allison Rogers Course NURS 5018

SOAP Note #5 Well-Woman Exam- Focused

Pt. Initials: P.S. Age: 43 DOB: 04-21-73 LMP: 06-28-2016
(S) CC: New patient establishment, well-woman examination.

HPI:

Character: (not applicable for this examination)

Onset: (not applicable for this examination)

Location: (not applicable for this examination)

Duration: (not applicable for this examination)

Severity: (not applicable for this examination)

Pattern: (not applicable for this examination)

Associated: Lost job and insurance last month (June 2016), wishes to become established as
new patient at free clinic and requests assistance with purchasing medications. Last pap test:
has been a while, last mammogram: 2013, and last colonoscopy and endoscopy: 2012.
Medical Hx: Migraine, hypertension, palpitations, chest pains, asthma, bulging lumbar disc,
right shoulder torn biceps, tendonitis, bursitis, right frozen shoulder, right knee torn meniscus
and anterior cruciate ligament, gout, chronic right ankle sprain, bilateral carpal tunnel syndrome,
increased prolactin level, whip lash (x3), pseudo seizures, restless leg syndrome, diverticulosis,
irritable bowel syndrome, acid reflux, overactive bladder, neuropathy, TIA (x2, last 2013),
myocardial infarction (2015), and uterine fibroid. Several hospitalizations with previous
surgeries, TIA, and MI, last hospitalization February 2016 due to uterine fibroid.
Surgical Hx: Diagnostic laparoscopy, Left Achilles tendon repair, dilation and curettage,
bilateral tubal ligation, endoscopy, colonoscopy
Social Hx: Lives with husband Michael of 20 years who has diagnosis of cystic fibrosis, has
three daughters and seven grandchildren all living outside of the home. Not currently employed,
states disabled since back surgery in 2001. Denies past or present tobacco, alcohol, or drug
use.
Family Hx: Mother (deceased, age 70s- heart attack) heart disease, hypertension; dad
(deceased, age 70s- heart attack) heart disease, hypertension; no siblings.

Allergies: Peanut Butter (throat swelling)

Meds: Lortab 10/325mg every 6 hours PRN, Valium 10mg three times daily, Fioricet one daily
PRN, Colace 100mg BID, Lasix 40mg once weekly and daily PRN, potassium chloride 10mEq
daily, Singulair 10mg daily, Ventolin MDI 2 puffs every 4-6 hours PRN, Albuterol nebulizer
0.083% every 6 hours PRN, aspirin 81mg daily, Protonix 40mg BID, Lisinopril 30mg daily,
nitroglycerin 0.4mg PRN, Flexaril 10mg every 8 hours PRN, Advair 250/50mg BID
ROS: General: States does not feel well rested, reports on average 6 hours of sleep per night,
interrupted due to chronic generalized pain. Denies fever, chills, fatigue, recent unexplained
weight gain/loss.
HEENT: Wears glasses for reading and distance, states is able to see well with use of glasses.
Reports occasional floaters. Denies head trauma, blurry vision, red or itchy eyes. Denies
congestion, post nasal drainage, nose bleeds, sneezing, hearing loss, or hoarseness.

Skin: Denies rash, hives, puritis, edema, ulcerations, moles, alopecia, excessive ecchymosis, or
erythema.

Respiratory: Reports slight shortness of breath on exertion, Denies cough, congestion,

wheezing, crackles, or hemoptysis.
Cardio: Reports chest and left arm pain on and off with exertion, states occurs approximately
once weekly with last episode being approximately six days ago, states has not taken
nitroglycerin for. Denies chest, arm, jaw, shoulder, or back pain today. Reports orthopnea, states
sleeps on five to six pillows each night, reports symptoms better with elevation of head. Reports
palpitations and feelings of fluttering of heart beat, states has worn monitors in the past but
they have never found anything wrong. States had stress test at local hospital in winter of 2015,
reports had slight heart attack during the test. States did not follow up due to loss of
insurance. Reports edema in bilateral legs and feet.
GI: Reports heartburn, internal and external hemorrhoids, and chronic constipation, states is
relieved with daily Colace use. Denies dysphagia, nausea, vomiting, diarrhea, loss of appetite,
black or bloody stools.
GU: Reports hesitancy and stress incontinence, states wears pad daily due to the incontinence.
Denies frequency, dysuria, urgency, nocturia, or hematuria. Reports knots in both breasts,
slight hot flashes at times during menstrual cycle, dysmenorrhea, states menstrual cycle is
approximately every 28 days, and usually ranges from 2 days to 5 days of heavy flow, soaking
one pad each hour. Denies vaginal dryness hirsutism, or nipple discharge.
Diet: Denies change in diet pattern. Reports eating three home cooked meals per day plus
snack, reports drinking water and green tea. States typically eats fast food few times per week
or less.
Endocrine: Reports polydipsia. Denies hot or cold intolerance, goiter, polyphagia, or polyuria.

MS: Reports generalized joint pain at times, states is worse when walking or with activity.
Denies swelling, decreased range of motion, muscle pain, or muscle spasms.
Neuro: Reports psudo seizures and starring into space, unable to remember the last episode,
states has been a while. Reports weakness in right arm and leg since last TIA in 2013. Denies
headaches, neuropathy, sudden loss of vision or speech, vertigo, or tremors.
Psych: Reports depression and anxiety at times, states she cleans house when she feels anxious
and that seems to help with the symptoms. Denies feelings of agitation, panic, suicidal thoughts
or tendencies, or hallucinations.
(O)

Vital signs: T: (not available) P: 70 R: 18 BP: 146/84 HT: 57 WT: 297 pounds BMI:
46.5 Pain: 4/10
Constitutional - Pleasant, well-groomed Caucasian woman, dressed appropriately for age and
weather. Cooperative and answers questions appropriately. No grimacing, guarding, or acute
distress noted.
HEENT: Normocephallic. No infestations, flakes, abrasions, raised areas noted to scalp,
eyebrows, eyelashes, or facial area. Pupils equal, round, reactive to light and accommodation,
2mm and brisk. Sclera white in color with no redness or irritations noted, conjunctiva pink. Red
reflex visualized in bilateral eyes. No nystagmus noted. Denies tenderness of pinna or tragus
bilaterally, tympanic membrane visualized, pearly gray bilaterally, no drainage, bulging, or
redness noted to membrane, or outer canal, no cerumen noted. Nasal passageways clear, no
redness, sores, deviated septum, polyps, or nasal drainage noted. Lips pink and moist, no
ulcerations or crustations noted. Oral cavity pink and moist, no ulcerations, dental caries, or
abnormalities noted, tongue midline, able to move freely without difficulty, no glossitis, palate
rises equally, uvula midline, tonsils visualized 2+ bilaterally, Trachea midline, thyroid palpated,
no goiter noted or tenderness reported. Facial, neck, and supracervical lymph nodes non-
palpable and non-tender.
Skin: Warm, dry, and intact, no lacerations, abrasions, ulcerations, ecchymosis, erythema, or
rashes.

Respiratory: Lungs clear all lobes bilaterally, no wheezing, crackles, or rhonchi noted. No
cough noted. Lung expansion equal and symmetrical bilaterally. AP diameter of chest 1:2, no
barrel chest noted. No clubbing of nailbeds.

Cardio: Regular rate rhythm, S1, S2 present, no rubs, gallops, murmurs noted. One+ pitting
edema noted to bilateral lower extremities. No jugular vein distension, spider veins, or
varicosities noted.
GI: Normoactive bowel sounds noted in all four quadrants. Abdomen non-distended, soft, non-
tender, no organomegally noted.
GU: No bladder distension noted. Denies CVA tenderness bilaterally.

Endocrine: No exophthalmos, goiter, hirsutism, or hyperhidrosis noted. Blood glucose 124

mg/dl.
MS: Muscle strength noted slightly diminished in right hand with gripping, foot pushes equal
and strong bilaterally. No swelling or redness noted to joint areas bilaterally. Full range of
motion noted to neck, back, bilateral shoulders, arms, fingers, hips, knees, ankles, and toes.
Neuro: Alert and oriented to person, place, time, and event. No tremors noted.

Psych: Appropriately interacts and answers questions, appropriate affect, no flat affect noted.
Does not appear anxious or in depressed mood, no fidgeting noted.

Other: Papanicolou (Pap) test and breast exam completed with chaperone present. No lesions
present to labia, vaginal wall or cervix, no nabothain cyst noted to cervix, no fishy odor or
discharge. Breast symmetrical with no dimpling, or nipple drainage noted. Multiple mobile, two
cm diameter or less, fibrocystic nodules noted to outer aspects of bilateral breast, reports slightly
tender upon palpation. No nodules noted or tenderness reported in axilla areas bilaterally.
Bimanual exam done, unable to palpate ovaries bilaterally.
(A)
Dx: (include ICD 10 code - http://www.icd10data.com/ICD10CM/Codes )(list as many
diagnoses as indicated)

Z00.0 Encounter for general adult medical exam; Z01.41 Encounter for routine gynecological
exam
Differentials:

1- N60.19 Diffuse cystic mastopathy of unspecified breast

2- I25.1 Arthrosclerotic heart disease of native coronary artery
3- I24.9 Acute ischemic heart disease, unspecified
4- G40.89 Other seizures
(P) (Include costs of tests, medications, etc. can find resources for this at
http://www.nlm.nih.gov/services/drug_procedure_costs.html; www.epocrates.com,
http://www.goodrx.com)
1. EKG- FREE at clinic. According to Cost Helper (2016b), the average cost for an EKG for an
uninsured patient can range from $500-$3,000 for the EKG and interpretation.
2. CBC- FREE at clinic. According to Cost Helper (2016a), the average cost for a CBC blood
test ranges from $10-$150.
3. CMP- FREE at clinic. According to Cost Helper (2016a), the average cost for a
comprehensive panel blood test ranges from $80-$1,500.
4. Mammogram at Remote Area Medical (R.A.M.)- FREE. According to Cost Helper (2016c),
the average cost of a mammogram ranges from $80-$120 for an uninsured patient.
5. Consult Neurologist at R.A.M.- FREE. (Unable to find typical cost of neurologist office
visit)
6. Consult Cardiologist at R.A.M.- FREE. (Unable to find typical cost of cardiologist office
visit)
7. Consult Endocrinologist at R.A.M.- FREE. (Unable to find typical cost of endocrinologist
office visit)
8. Will obtain records from previous health care provider.

Pt.Education:_Use nitroglycerin as prescribed at the onset of chest pain or angina. Call 911 if
chest pain unrelieved after second dose of nitroglycerin. Always notify health care provider of
angina attacks that require the use of nitroglycerin. Informed patient that females do not often
have classic symptoms when experiencing a heart attack, symptoms often present as neck, jaw,
shoulder, back, or arm pain, or can also mimic heartburn or acid reflux. Instructed to notify
practitioner of new symptoms or worsening seizure activity. Fibrocystic changes in breast are
normal, especially in women ages 30-50, and are not a precursor to breast cancer. Symptoms are
often worse and noticed around the time of menstrual period. Previous research has suggested
that reducing amounts of caffeine (such as the green tea) could help to decrease symptoms. The
mammogram should show if there are any concerning changes to the breast tissue or area of
concern that need further investigation.
Preventive care: Reduce caffeine intake, may take Vitamin E 1000mg or 1500IU once daily in
hopes to reduce symptoms of fibrocystic changes of the breast. Follow a cardiac diet, decreasing
the amounts of fried and increased sodium foods. Encouraged to elevate legs as much as
possible and elevate on pillow at night to help reduce edema.
Follow-up instructions: Will notify of Pap test results when available, approximately one
week. Mammogram, Neurology, Endocrinology, and Cardiology consult at the upcoming local
R.A.M. Follow up at the Health Wagon clinic one week after R.A.M. (approximately one month
from now).
Other: None

Discuss how you addressed at least 3 NONPF competencies during this visit. (See
NONPF competency list available at
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecom
petenciesfinal2012.pdf )

1. Health Delivery System Competencies

According to Thomas et al. (2014), this competency is fulfilled by understanding needs of the
population served, as well as utilizing community resources and system outreach to the
community. This clinical site serves persons who are unable to financially meet their medical
needs. Through being conscious of the unique needs of this patient, the mammogram, as well as
the Neurology, Cardiology, and Endocrinology consults were suggested by utilizing the
upcoming R.A.M. clinic, which offers free medical, vision, and dental consults, as well as
providing testing, treatments, and resources in order to meet the needs of the community.
2. Independent Practice Competencies
Thomas et al. (2014) states this competency is fulfilled through providing patient-centered care,
working to establish a relationship with the patient characterized by mutual respect and
collaboration as well as providing confidentiality, privacy, comfort, and emotional support. I feel
this competency was fulfilled through working to establish a trusting relationship with the first
patient encounter and providing the best care possible for the patient with available resources.
3. Practice Inquiry Competencies
According to Thomas et al. (2014), this competency is fulfilled by applying clinical investigative
skills to improve health outcomes, as well as exploring behaviors and risk factors. I fell this
competency is fulfilled through noticing risk factors, such as familial tendencies of disease
processes, such as heart disease, and assessing behavioral associated risk factors such as the
preparation of meals and the consumption of caffeinated drinks. Also by obtaining the patients
previous health records, studying previous diagnoses and coming up with a current plan for the
patient.
 References

Cost Helper [Internet]. (2016a). Blood test cost: How much do blood tests cost? Retrieved

from costhelper.com website: http://health.costhelper.com/blood-test.html

Cost Helper [Internet]. (2016b). EKG cost: How much does an EKG cost? Retrieved from

costhelper.com website: http://health.costhelper.com/ecg.html

Cost Helper [Internet]. (2016c). Mammogram cost: How much does a mammogram cost?

Retrieved from costhelper.com website: http://health.costhelper.com/mammogram.html

Thomas, A. C., Crabtree, M. K., Delaney, K., Dumas, M. A., Kleinpell, R., Marfell, J. Wolf,

A. (2014). Nurse practitioner core competencies. The National Organization of Nurse

Practitioner Faculites. Retrieved from:

http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcor

ecompetenciesfinal2012.pdf