KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT

ADULT, WOMEN, GERIATRICS

Student: Allison Rogers Course: NURS 5019

SOAP Note # 2 (41-60 year old)

Pt. Initials: M.L. Age: 44 DOB: 03-07-1972 LMP: N/A (Male)
(S) CC: Physical exam- New patient establishment

HPI:

Character: (not applicable to this exam)

Onset: (not applicable to this exam)

Location: (not applicable to this exam)

Duration: (not applicable to this exam)

Severity: (not applicable to this exam)

Pattern: (not applicable to this exam)

Associated: Patient states, My primary care doctor recently retired, and I just wanted to get
established with another doctor, especially because of my family history. Reports recent lab
work at PCP office within past six months, all within normal limits.
Medical Hx: Arthritis, erectile dysfunction

Surgical Hx: Right knee arthroscopy, colonoscopy x2 (with polyp removal in 2009)

Social Hx: Lives at home with wife and two daughters, ages 13 and 17. Reports monogamous
relationship with wife and good support system. Works as engineering technician at Eastman,
reports likes his job. Dips one can of scoal every few days, for approximately ten years. Denies
current or past cigarette, alcohol or illicit/ recreational drug use. Reports walking one to two
miles daily, while at work, and strength training, with moderate weights, approximately three
times per week. Denies recent travel within or out of the country.
Family Hx: Mom- (deceased age 63- complications of colon cancer) colon cancer (age 62);
Dad- (deceased age 73- complications with metastasis) colon cancer (age 56), metastasis to lung
and prostate, diabetes

Allergies: No know food, drug, latex, or metal allergy

Meds: Cialis 20mg daily PRN

ROS: General: Reports feeling well rested. Denies recent fever, chills, night sweats, fatigue,
or weight changes.
HEENT: Denies changes in vision or hearing, tinnitus, nasal/ sinus problems, hoarseness, or dry
mouth.

Skin: Denies rashes, bruising, itching, dryness, discolorations, changes in moles, or changes in
hair.

Respiratory: Denies dyspnea, cough, wheezing, snoring, or hemoptysis.

Cardio: Denies chest pains/ angina, palpitations, orthopnea, edema, exertion with exercise or
activity.
GI: Denies nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort, dysphagia,
odynophagia, or rectal bleeding. Last colonoscopy 2011, no polyps, MD suggested to repeat in 5
years.
GU: Denies frequency, hesitancy, dysuria, nocturia, hematuria, or incontinence. Last digital
prostate exam 2011, normal. Reports Cialis is working well.
Diet: Denies change in diet or pattern of eating. Reports drinking mostly water, with coffee or
soda approximately one time per day. Reports typically energy bar, sometimes skipping,
breakfast, fast food for lunch, and eating home cooked supper.
Endocrine: Denies heat/ cold intolerance, hyperhidrosis, polyuria, polyphagia, polydipsia,
goiter, or exophthalmos.
MS: Denies muscle or joint weakness or stiffness, myalgia, arthralgia, swelling, limited range of
motion, or back pain.
Neuro: Denies headaches, dizziness, weakness, numbness, tingling, burning, tremor, or
seizures.
Psych: Denies anxiety, depression, suicidal/ homicidal thoughts or tendencies.

(O)

Vital signs: T: 96.2F P: 72 R: 16 BP: 122/78 HT: 6 WT: 223 pounds BMI: 30.2
Pain: 0 (denies)

Constitutional Pleasant, well-groomed, well-nourished Caucasian male. Dressed

appropriately for age and weather. Cooperative and answers questions appropriately. No
grimacing, guarding, fidgeting, or distress noted.
HEENT: Normocephallic. No infestations, flakes, abrasions, raised areas noted to scalp,
eyebrows, eyelashes, or facial area. Sclera white in color with no redness or irritations noted,
conjunctiva pink. Pupils equal, round, 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, small amount of yellow cerumen noted bilateral.
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, leukoplakia, 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. No edema noted
to upper/ lower extremities. No jugular vein distension, bruits, smspider veins, or varicosities
noted.
GI: Normoactive bowel sounds noted in all four quadrants. Abdomen non-distended, soft, non-
tender.
GU: No bladder distension noted. Denies CVA tenderness bilaterally.

Endocrine: No exophthalmos, goiter, hirsutism, or hyperhidrosis noted.

MS: No swelling or redness noted to joint areas bilaterally. Full range of motion noted to neck,
back, bilateral shoulders, arms, fingers, hips, knees, and ankles.
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: None

(A)
Dx: (include ICD 10 code - http://www.icd10data.com/ICD10CM/Codes )(list as many
diagnoses as indicated)

Z00.00 Encounter for routine general medical exam; N52.9 Male erectile dysfunction,
unspecified; E66.9 Obesity, unspecified; Z72.0 Tobacco use; Z80.0 Family history of malignant
neoplasm of digestive organs, Z80.1 Family history of malignant neoplasm of trachea, bronchus,
and lung, Z80.42 Family history of malignant neoplasm of the prostate
Differentials:

1- K13.21 Leukoplakia of oral mucosa, including tongue

 2- K02.9 Dental caries, unspecified
3- K05.6 Periodontal disease, unspecified
4- C06.9 Malignant neoplasm of the mouth, unspecified
5- C15.9 Malignant neoplasm of the esophagus, unspecified
6- C25.9 Malignant neoplasm of the pancreas, unspecified
7- I51.9 Heart disease, unspecified
8- I63.9 Cerebral infarction, unspecified
9- I73.9 Peripheral vascular disease, unspecified
(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- Will obtain lab results from previous PCP and repeat if needed, or
at follow up visit. Labs to obtain for routine physical exam for 44 year-old male with no
complaints or abnormal findings include: CBC, CMP, and Lipids (Peterson, 2017).

Pt.Education: Smokeless tobacco use has increased incidence of developing cancers of the
mouth, esophagus, and pancreas, as well as causing periodontal disease, heart disease, and stroke
(Centers for Disease Control and Prevention, 2016). Discussed with patient naming a quit date
for smokeless tobacco (Patient states will think about it, not interested in medication intervention
or counseling at this time).
Discussed the importance of reporting any signs of symptoms of leukoplakia, mouth, or
esophageal cancers. Signs and symptoms to report include white patches in the mouth or on the
tongue that lasting for more than 2 weeks, dysphagia or difficulty swallowing, odynophagia or
painful swallowing, hoarseness, anorexia, unexplained weight loss (Law, 2017; Lyden, 2017).
Colon cancer has familial tendencies. It is very important to keep follow up appointments and
regular colonoscopies as already scheduled per gastroenterology. Please notify healthcare
provider of any signs or symptoms, such as gastrointestinal changes, fatigue, shortness of breath,
black/ bloody stools, anorexia, and unexplained weight loss (Law, 2017).
Preventive care: Follow up with gastroenterologist as scheduled. Colonoscopy as scheduled.
According to Law (2017), promotion of a healthy lifestyle is essential in colorectal cancer
prevention. Limited fat intake, increased fiber, and regular exercise, for 30 minutes at least three
times per week, the more vigorous the exercise the more benefit will provide. Avoidance of
tobacco and alcohol is also important (Law, 2017).
Cancer of the colon, among others cancers, as well as many disease processes including erectile
dysfunction and heart disease, is associated with obesity (Grantham, 2017). A goal was set to
increase in aerobic exercise, at least three times per week, and decreasing fast food intake.
Follow-up instructions: Follow up in one year, or sooner as needed.

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- Scientific Foundation Competencies

According to Thomas et al. (2014), this competency is met through comparison of patient data
sets with evidence-based standards to improve care. I feel that I have met this competency by
evaluating and taking into consideration the patients vital signs, BMI, review of systems,
physical exam, medications, social, and family history in making an assessment and using
standards of care to compile a plan.

2- Quality Competencies
Thomas et al. (2014) states this competency is met through cost benefit analysis and using
collaborative team process and practice. This competency was met by collaborating and
requesting recent lab results from previous primary care provider, in an attempt to decrease cost
for the patient.

3- Independent Practice Competencies

An independent practice competency is met through health promotion, prevention, and
screenings (Thomas et al., 2014). This competency was met by reviewing social and family
histories and health promotion and prevention education on tobacco cessation, as well as signs
and symptoms to report. The importance of keeping scheduled screenings, such as colonoscopy,
was also discussed with patient.
 Reference

Centers for Disease Control and Prevention, Office on Smoking and Health, National Center for

Chronic Disease Prevention and Health Promotion (2016, February 18). Smokeless

tobacco health effects [Fact Sheet]. Retrieved from:

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/health_effects/index.ht

Grantham, S. L. (2017). Obesity and weight management. In T. M. Buttaro, J. Trybulski, P.

Polgar-Bailey, & J. Sandberg-Cook (Eds.), Primary Care: A Collaborative Practice (5th

ed.), (pp.109-125). St. Louis, MO: Elsevier.

Law, L. (2017). Tumors of the gastrointestinal tract. In T. M. Buttaro, J. Trybulski, P. Polgar-

Bailey, & J. Sandberg-Cook (Eds.), Primary Care: A Collaborative Practice (5th ed.),

(pp.722-727). St. Louis, MO: Elsevier.

Lyden, E. A. (2017). Pharyngitis and tonsillitis. In T. M. Buttaro, J. Trybulski, P. Polgar-Bailey,

& J. Sandberg-Cook (Eds.), Primary Care: A Collaborative Practice (5th ed.), (pp.413-

416). St. Louis, MO: Elsevier.

Peterson, K. (2017). Lifestyle management. In T. M. Buttaro, J. Trybulski, P. Polgar-Bailey, & J.

Sandberg-Cook (Eds.), Primary Care: A Collaborative Practice (5th ed.), (pp.125-145).

St. Louis, MO: Elsevier.

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