You are going to create a soap note about this patient here: D.W is a 29-year-old G2P1 female presents to the clinic with complaints of sharp, intermitten
You are going to create a soap note about this patient here: D.W is a 29-year-old G2P1 female presents to the clinic with complaints of sharp, intermittent lower abdominal pain on the right side that started three days ago. She reports that the pain has gradually worsened and is now constant, radiating to her lower back. She also notes light vaginal spotting, which she initially thought was an irregular period, but it has continued for several days. The patient states that she has been feeling lightheaded and nauseous since this morning. Her last menstrual period (LMP) was six weeks ago, and she has a history of irregular cycles. She had a positive home pregnancy test one week ago but has not yet had her first prenatal visit. She denies passing clots, fever, chills, dysuria, or recent infections.
Her past obstetric history includes one prior full-term vaginal delivery without complications. She has no known history of sexually transmitted infections (STIs), pelvic inflammatory disease (PID), or previous ectopic pregnancy. However, she does report a prior laparoscopic appendectomy at age 22. The patient is sexually active in a monogamous relationship and has not been using contraception.
On physical examination, she appears slightly pale and uncomfortable but is alert and oriented. Her vital signs show mild tachycardia (HR: 102 bpm), normal blood pressure (110/70 mmHg), and normal temperature (98.6°F). A pelvic examination reveals mild cervical motion tenderness, significant right adnexal tenderness, and a slightly enlarged uterus. No significant vaginal bleeding is observed. I am attaching the template so you can develop one. In addition to that I am attaching my previous one so you can understand about the references and in text citations and per reviewed rationales. Instructions:
nstructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient's condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up . SOAP starts Begins with patient initials, age, race, ethnicity and gender (5 demographics)
Chief Complaint (Reason for seeking health care)
4 to >3 pts
Includes a direct quote from patient about presenting problem
History of the Present Illness (HPI)
5 to >3 pts
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
Allergies
2 to >1.5 pts
Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
Review of Systems (ROS)
15 to >8 pts
Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”
Vital Signs
2 to >1.5 pts
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
Labs
2 to >1.5 pts
Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.
Medications
4 to >2 pts
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)
Past Medical History
3 to >2 pts
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
Past Surgical History
3 to >2 pts
Includes, for each surgical procedure, the year of procedure and the indication for the procedure
Family History
3 to >2 pts
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
Social History
3 to >2 pts
Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
Health Maintenance / Screenings
3 to >2 pts
Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests
Physical Examination
15 to >8 pts
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint
Diagnosis
5 to >3 pts
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) with in text citation
Differential Diagnosis
5 to >3 pts
Includes at least 3 differential diagnoses for the principal diagnosis with in text citations
ICD 10 Coding
3 to >2 pts
Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit
Pharmacologic treatment plan
5 to >3 pts
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. AL L with in text citations- references.
Diagnostic / Lab Testing
3 to >2 pts
Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
Education
3 to >2 pts
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
Anticipatory Guidance
3 to >2 pts
Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening)) all with in text citations and references
Follow Up Plan
2 to >1 pts
Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)
Prescription
3 to >2 pts
Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials
Writing Mechanics, Citations, and APA Style
3 to >2 pts
Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors. Include at least 6 References.
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SOAP NOTE TEMPLATE Review the Rubric for more Guidance |
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Demographics |
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Chief Complaint (Reason for seeking health care) |
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History of Present Illness (HPI) |
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Allergies |
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Review of Systems (ROS) |
General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: |
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Vital Signs |
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Labs |
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Medications |
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Past Medical History |
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Past Surgical History |
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Family History |
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Social History |
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Health Maintenance/ Screenings |
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Physical Examination |
General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: |
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Diagnosis |
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Differential Diagnosis |
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ICD 10 Coding |
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Pharmacologic treatment plan |
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Diagnostic/Lab Testing |
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Education |
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Anticipatory Guidance |
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Follow up plan |
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Prescription |
See Below (scroll down) |
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References |
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Grammar |
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EA#: 101010101 STU Clinic LIC# 10000000 |
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Tel: (000) 555-1234 FAX: (000) 555-12222 |
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Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
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7
Perimenopause SOAP Note 1
Alexsandra Lima
St. Thomas University
NUR-514CL-AP7.25/ADVANCED FNP WOMEN'S HEALTH
Dr. Velasquez Marichal
01/26/2025
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SOAP NOTE TEMPLATE |
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Demographics |
Name: A.B. Age: 48 years old Gender: Female |
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Chief Complaint (Reason for seeking health care ) |
“I am having severe hot flashes, mood swings, weight gain around my waist, and vaginal dryness.” |
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History of Present Illness (HPI) |
A.B. is a pleasant 46-year-old white female presenting to the clinic with a 6-month history of worsening climacteric symptoms, including 6–8 daily hot flashes, night sweats, mood swings, irritability, and unwanted weight gain around the waist. She describes the hot flashes as sudden, intense sensations of heat, primarily affecting her face and chest, accompanied by sweating, which disrupt her daily activities. The night sweat disturbs her sleep, causing fatigue and irritability during the day. A.B. reports significant mood changes, including increased emotional sensitivity and difficulty managing stress, which is affecting her personal and work life. She has also noticed progressive weight gain concentrated around her midsection, despite no major changes in her diet or activity level. Her menstrual history reveals irregular cycles over the past year, with periods occurring every 35–50 days and lasting 2–3 days, lighter than her usual flow. She denied any vaginal bleeding in the past three months. A.B. denies breast tenderness, hair loss, or acne but reports vaginal dryness, which has led to mild discomfort during intercourse. She denies urinary symptoms, such as dysuria or urgency. There is no history of galactorrhea, headaches, or visual disturbances. She denies symptoms of thyroid dysfunction, including heat or cold intolerance, palpitations, or tremors. A.B. has a history of hypertension, well-controlled on Losartan 50 mg daily. She denies any other chronic illnesses or medications. She has a surgical history of two cesarean sections (G2P2002) . She denies any history of spontaneous or elective abortions. She denies any history of STIs. She is a nonsmoker, does not consume alcohol, and denies recreational drug use. Her family history is significant for her mother’s diagnosis of sarcopenia and menopause-related osteoporosis at the age of 60. She engages in regular physical activity and is open to adopting diet lifestyle modifications. |
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Allergies |
No known allergies. |
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Review of Systems (ROS) |
General: The patient reports a history of fatigue, night sweats and weight gain around waist, but denies experiencing fever, changes in appetite, or sensitivity to heat or cold. HEENT: Head: She denies headaches, head trauma, or episodes of lightheadedness. Eyes: She denies conjunctival icterus, excessive tearing, vision loss, blurred vision, eye infection. She has presbyopia and wear glasses to read. Ears: She reports no tinnitus, earaches, infection, discharge or hearing loss. Nose: She denies epistaxis, septum deviation, sinus infection, nose discharge, sneezing. Throat: She denies changes in voice, difficulty swallowing and throat tenderness and redness. Neck: denies tenderness, masses or pain against resistance. Lungs: She denies SOB, exposure to tuberculosis, coughing, sputum production, adventitious sounds, or coughing up blood. Cardio: She denies heart palpitations or pain, swelling in the extremities, difficulty breathing, or any history of dysrhythmias. Breast: Denies tenderness, masses and no discharge. GI: Reports moving her bowls daily, denies GERD, epigastric pain, nausea, vomiting and diarrhea. M/F genital: Reports vaginal dryness, denies redness and discharge. GU: Reports dyspareunia, reduced libido. Denies urinary urgency, dysuria, anuria or hematuria or STIs. She reports that her menstrual cycles are irregular, she has two children born both through C-sections, is sexually active, with a partner and uses the rhythm cycle as a contraceptive method. She denies painful menses, previous abortions or miscarriages and any BHRT or HRT. Neuro: Denies epileptic episodes, loss of consciousness, numbness, dyskinesia, migraines, paresthesia and memory loss. Musculo: denies any ROM problems, stiffness, joint swelling or pain. Activity: Reports exercising twice a week despite fatigue and disrupted sleep. Psychosocial: Reports on Irritability and mood swings. Denies suicidal thoughts. Derm: Denies rashes, alopecia, skin/nail fungus, itchiness, redness, skin discoloration, lesions and lumps. Nutrition: Reports eating three meals per day, but reports a habit of consuming fast food. Sleep/Rest: Wakes up frequently due to night sweats, reports sleeping 4 hours per night. LMP: 3 months ago. STI Hx: Denies any infections of sexually transmitted diseases. |
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Vital Signs |
Blood Pressure: 126/78 mmHg Heart Rate: 76 bpm Respirations: 18 breaths/min Temperature: 94.6°F BMI: 28 |
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Labs |
CBC, FSH, LH, Estradiol, Progesterone, Prolactin, testosterone free and total, TSH, and lipid profile were completed to assess her menopausal status and exclude thyroid dysfunction. Results are consistent with perimenopause: FSH: 38mIU/mL, LH: 15mIU/mL, Estradiol 20pg/mL, Progesterone: 0.5ng/m, Prolactin: 12ng/mL (Lee et al., 2020) |
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Medications |
Currently medication: Losartan 50 mg tab orally daily in the morning for chronic hypertension (Rabi et al., 2020). |
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Past Medical History |
Chronic hypertension was diagnosed 2 years ago and managed with Losartan. |
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Past Surgical History |
Cesarean section (2). (2001), (2003). Breast Implants at 24 years old. |
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Family History |
Mother with a history of sarcopenia, osteoporosis and hypertension; father with a history of type 2 diabetes. |
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Social History |
She does not smoke, drinks a glass of wine on weekends, and does not use recreational drugs. |
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Health Maintenance/ Screenings |
Mammogram: 2023, normal. Colonoscopy: Age-appropriate, normal. Bone density scan: Pending. |
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Physical Examination |
General: Alert and oriented. She appears tired but in no acute distress. HEENT: Normocephalic, with clear conjunctiva and no scleral icterus noted. Neck: Soft, no lymphadenopathy, trachea is midline with slight deviation to the right. Lungs: Clear to auscultation bilaterally. Cardio: Regular rate and rhythm, no murmurs. Breast: No tenderness, masses, nipple diversion or discoloration, no discharge during breast examination. GI: Soft, non-tender abdomen, normal active bowel sounds. M/F genital: The vaginal mucosa appears pale, dry, thin and lacks normal lubrication, labia minora and majora appear atrophied and less plump, discomfort on palpation of the vaginal introitus and reduced vaginal secretions noted upon a speculum exam. GU: Deferred. Neuro: Normal. No focal deficits. Musculo: No tenderness or swelling. Activity: Reports limitations because of fatigue. Psychosocial: Mildly apprehensive about symptoms. Derm: No rash or lesions seen. |
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Diagnosis |
Primary: Perimenopause (N95.0) Perimenopause is the transitional phase before menopause characterized by fluctuating hormone levels. Symptoms such as irregular menstrual cycles, hot flashes, mood changes, and vaginal dryness overlap with menopause. Perimenopause should be considered if the patient is still experiencing irregular periods, as hormonal fluctuations can precede the cessation of menses for several years (North American Menopause Society, 2022). |
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Differential Diagnosis |
Polycystic Ovary Syndrome (PCOS) (E28.2) PCOS can present with weight gain, mood changes, and irregular menses. While vaginal dryness is less common, metabolic disturbances in PCOS can exacerbate weight gain. Differentiating PCOS from menopause or perimenopause requires evaluating androgen levels and imaging for ovarian cysts (Teede et al., 2018). Menopause (N95.1) Menopause is diagnosed when a woman has not had a menstrual period for 12 consecutive months and experiences symptoms related to decreased estrogen levels. Hot flashes, mood swings, unwanted weight gain around the waist, and vaginal dryness are hallmark symptoms of menopause (Santoro et al., 2021). These symptoms result from ovarian follicular depletion and the associated decline in estradiol production, which impacts thermoregulation, mood, fat distribution, and Hypothyroidism (E03.9) Hypothyroidism can present with symptoms such as fatigue, mood swings, weight gain, and menstrual irregularities, which overlap with menopausal symptoms. A thyroid-stimulating hormone (TSH) test would differentiate this condition, as hypothyroidism requires specific treatment with levothyroxine (Chaker et al., 2017). |
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ICD 10 Coding |
Polycystic Ovary Syndrome (PCOS)(E28.2) Menopause (N95.1) Hypothyroidism (E03.9) |
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Pharmacologic treatment plan |
Hormone Replacement Therapy (HRT): Symptomatic treatment with low-dose estradiol 0.5 mg and medroxyprogesterone 2.5 mg daily based on FSH (95 mIU/mL) and estrogen (20 pg/mL) levels (Yuksel et al., 2021). Vaginal estrogen cream: Estradiol 0.01% cream, apply intravaginally twice weekly based on vaginal atrophy results (Faubion et al., 2020). |
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Diagnostic/Lab Testing |
CBC, FSH, TSH, and lipid profile: FSH: 95 mIU/mL, LH: 52 mIU/mL, Estrogen: 20 pg/mL, Progesterone: 0.5 ng/mL, Prolactin: 12 ng/mL. |
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Education |
Discussed the benefits and risks of HRT, such as cardiovascular and breast cancer risks (Marsden & Pedder, 2020). Educating the patient on the importance of a balanced diet, regular exercise, and stress reduction can mitigate weight gain and improve mood. Weight loss may help reduce hot flashes. Behavioral therapy and mindfulness-based techniques are also beneficial (North American Menopause Society, 2022). Discuss alternative treatment if patient is unable or unwilling to take HRT, non-hormonal options like selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may help alleviate hot flashes. Low-dose paroxetine is an FDA-approved option (Santoro et al., 2021). |
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Anticipatory Guidance |
Instructed the patient on the importance of stress-reduction techniques that include weight-bearing exercises to support the health of bones (McKinney, 2021). Educated the patient on signs of abnormal uterine bleeding and instructed her to report immediately (McKinney, 2021). Discussed the importance of routine breast self-examinations (Yuksel et al., 2021). Recommended avoiding alcohol intake to reduce cardiovascular risk (McKinney, 2021). The North American Menopause Society provides detailed recommendations on managing menopausal symptoms, emphasizing individualized care for hormone therapy (North American Menopause Society, 2022). Clinical guidelines from the Endocrine Society support hormone replacement therapy for symptomatic relief, balancing benefits and risks for each patient (Santoro et al., 2021). The American College of Obstetricians and Gynecologists endorses vaginal estrogen therapy for treating genitourinary syndrome and advises lifestyle interventions for weight management (Kingsberg et al., 2020). |
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Follow up plan |
Follow-up scheduled in 6 weeks to assess treatment response. |
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Prescription |
See Below” |
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References |
Faubion, S. S., Kingsberg, S. A., Clark, A. L., Kaunitz, A. M., Spadt, S. K., Larkin, L. C., … & McClung, M. R. (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 27(9), 976-992. Lee, S. R., Cho, M. K., Cho, Y. J., Chun, S., Hong, S. H., Hwang, K. R., … & Kim, T. (2020). The 2020 menopausal hormone therapy guidelines. Journal of menopausal medicine, 26(2), 69. Marsden, J., & Pedder, H. (2020). The risks and benefits of hormone replacement therapy before and after a breast cancer diagnosis. Post Reproductive Health, 26(3), 126-135. McKinney, A. (2021). Lifestyle Medicine in Menopause and Bone Health. In Improving Women’s Health Across the Lifespan (pp. 255-272). CRC Press. Rabi, D. M., McBrien, K. A., Sapir-Pichhadze, R., Nakhla, M., Ahmed, S. B., Dumanski, S. M., … & Daskalopoulou, S. S. (2020). Hypertension Canada’s 2020 comprehensive guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children. Canadian Journal of Cardiology, 36(5), 596-624. Yuksel, N., Evaniuk, D., Huang, L., Malhotra, U., Blake, J., Wolfman, W., & Fortier, M. (2021). Guideline No. 422a: Menopause: vasomotor symptoms, prescription therapeutic agents, complementary and alternative medicine, nutrition, and lifestyle. Journal of Obstetrics and Gynaecology Canada, 43(10), 1188-1204. Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. The Lancet, 390(10101), 1550-1562. https://doi.org/10.1016/S0140-6736(17)30703-1 Kingsberg, S. A., Schaffir, J., & Krychman, M. L. (2020). Female sexual health: Vaginal health and hormone therapy. Obstetrics & Gynecology, 135(4), 975-988. https://doi.org/10.1097/AOG.0000000000003756 Santoro, N., Epperson, C. N., & Mathews, S. B. (2021). Menopausal symptoms and their management. JAMA, 325(23), 2448-2459. https://doi.org/10.1001/jama.2021.5052 The North American Menopause Society. (2022). The 2022 hormone therapy position statement. Menopause, 29(7), 767-794. https://doi.org/10.1097/GME.0000000000002005 |
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Grammar |
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