KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT

ADULT, WOMEN, GERIATRICS
Student: Susan Kelly Course: 5018

SOAP Note #2 Well-Women

Pt. Initials: R.J. Age: 35 DOB:1-23-1982 LMP:5-20-2017

(S)
CC: Establishing care, physical exam
HPI:
Character: Not pertinent
Onset: Not pertinent
Location: Not pertinent
Duration: Not pertinent
Severity Not pertinent
Pattern: Not pertinent
Associated: Not pertinent
Medical Hx: G 1, T 1, P 0, A 0, L 1 Denies medical issues
Surgical Hx: Denies previous surgeries
Social Hx: Lives in a single-family one level home equipped with smoke detectors with her
husband and their two-year-old son. Reported breastfeeding for six weeks postpartum then
returning to work transitioning to bottle-feeding at this time. Employed currently at a medical
office as a secretary, enjoys her job and interactions with co-workers. Reports good family
support. Attends bible study weekly and participates in an extended family dinner weekly.
Denies alcohol, tobacco, and illicit drug use. Reports wearing a seatbelt when driving and
encourages her passengers to do so. Reports immunizations, eye, dental, and hearing exams are
up to date, documentation provided to include in current record.
Family Hx: Reports obesity mother, father, and both maternal and paternal grandparents. Denies
additional medical or surgical family history at this time. Reports mother and father are involved
with a weight loss clinic and attend support group weekly to meet their goals.

Meds/Allergies: NKA
Motrin 200mg PO PRN
ROS:
General: Denies fever, chills, unexpected weight loss or gain. Reports adequate rest 6 to 8 hours
a night. Reports a safe home and work environment, denies episodes of violence. Reports good
intimate relations with no physical or mental abuse.
HEENT: Denies change in vision or hearing, tinnitus, nasal/sinus problems, hoarseness, or dry
mouth.

Skin: Denies rashes, ecchymosis, puritis, dryness, discolorations, changes in moles or changes in
hair.

Respiratory: Denies shortness of breath, coughing, wheezing, or snoring

Cardio: Denies chest pain, palpitations, edema, swelling, or exertion with exercise or activity.
GI: Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or discomfort. Denies
difficulty swallowing, chocking episodes, difficulity swallowing or rectal bleeding.
GU: Denies polyuria, dysuria, anuria, hematuria, or incontinence. Last Papanicolaou (PAP) test
was a year ago, reports normal results.
Endocrine: Denise heat/cold intolerance, excessive sweating, urination, thirst, or increase
appetite.
MS: Denies muscle/joint pain, weakness, or tenderness. Denies limited ROM neck or back pain.
Neuro: Denies headaches, dizziness, weakness, numbness, tingling, burning, tremors, or seizures.
Psych: Denies feelings of depression, anxiety, suicidal/homicidal thoughts, or tendencies.

(O)
Vital signs: T:98.8 P: 80 R: 20 BP: 118/70 HT: 5’5” WT: 180 BMI: 29.95 Pain: 0/10
Constitutional: Pleasant, well-mannered, well groomed, well-nourished Caucasian female.
Dressed appropriately for age and weather. Cooperative, made eye contact and answered
questions appropriately. No grimacing, fidgeting, or distress noted.
HEENT: Normocephalic, no infestations, flakes, abrasions, or raised areas noted on scalp,
eyebrows, eyelashes or facial area. Scelara white in color with no redness or irritation noted,
conjunctiva pink and moist. PERRL no nystagmus noted. Denies tenderness of pina or tragus
bilaterally, tympanic membrane visualized, bilateral pearly gray no drainage, bulging, redness, or
cerumen noted to outer canal or membrane. No obstruction noted to nasal passages, no redness,
sores, septal deviation, polyps or drainage. Lips pink and moist without sores or crustations. Oral
cavity pink and moist, no ulcerations, leukoplakia, or dental caries noted. All teeth are present.
Tongue midline adequate ROM, no glossitis, uvula midline, tonsils palpated non-tender,
visualized bilateral 2+. Trachea midline, thyroid palpated, no goiter or tenderness noted. Facial,
neck and cervical lymph nodes non-palpable, non-tender.
Skin: Pink, warm and dry to touch. No lacerations, abrasions, ulcerations, ecchymosis, erythema,
or rashes.

Respiratory: All lobes clear to auscultation bilaterally. No wheezing, crackles or ronchi noted.

Cardio: S1 S2 RRR No gallops, rubs or murmurs noted. No JVD or bruits, no edema noted
bilateral upper and lower extremities
GI: Non-tender non-distended bowel sounds positive times four quadrants. Abdomen
nondistended, soft, non-tender.
GU: No bladder distension or CVA tenderness noted.
Endocrine: No exophthalmos, goiter, hirsutism or hyperhidrosis noted.
MS: Full ROM strength 5/5 bilateral upper and lower extremities, neck and back. No redness or
edema noted in the joints.
Neuro: Alert and oriented times three. Steady gait and balance.
Psych: Appropriate affect answers all questions appropriately. Does not present anxious or
fidgets no depressed mood noted.

(A)
Dx: Routine medical exam Z01.41
Overweight E66.3
Differentials:
2. Thyroid disorder E07.9
1. Obesity Z13.89
3. Binge eating F50.81

(P)
(Include costs of tests, medications, etc. – can find resources for this at
http://www.nlm.nih.gov/services/drug_procedure_costs.html

Complete Metabolic Panel (CMP) $58.00

Complete Blood Count (CBC) $38.00
Thyroid Stimulating Hormone (TSH) $75.00
Free T4 $49.00
Lipid Panel $29.00
Urinalysis $9.00

Follow-up: 1 year for physical exam and pap in 3 years.

Pt. Education: Patient was educated on weight loss options both dietary and pharmacotherapy.
Patient preferred diet and exercise at this time. Patient was instructed to watch food labels for
hidden calories and carbohydrates. Patient was instructed to limit sugary drinks. Liquid
kilocalories, such as strong satiety signaling properties as solid foods, which can lead to greater
kilocalorie ingestion throughout the day (Grantham, 2017). Encouraged to be mindful of portion
size, literature given to support recommendations. Instructed to exercise at least 30 minutes a day
recommended brisk walking, bicycling, and swimming. (Grantham, 2017). Also, recommended
an hour gym time daily and taking time out for herself which she stated her husband was very
supportive of and he allowed her to gain adequate sleep at night.

Preventative Care: Patient was instructed to maintain wellness checks as recommended such as
pap test and breast exams every three years for ages 21years and over (Kauschinger & Sandberg-
Cook, 2017). American Cancer Society recommends beginning at age 20 United States
Preventative Services Task Force recommends against teaching breast self-exam (Kauschinger &
Sandberg-Cook, 2017). Informed of the importance of self-breast awareness and the subtle
changes throughout the menstrual cycle, however, lingering changes should be followed-up on as
early detection is the best protection. Recommended the utilization of sunscreen this time of year
and limit exposure to the sun and tanning beds.

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/npcorecompetenciesfina
l2012.pdf )

1. Scientific Foundation Competencies

This competency was met by evaluating patient data and relating it to evidence based
practice to develop the appropriate plan of care.

2. Independent Practice Competencies

This competency was met by the review of family and social history and providing
preventative and promotional education. The patients was instructed of the importance of
maintaining her scheduled appointments and taking ownership of her health related
status.

3. Technology and Information Literacy Competencies

This competency was met by the utilization of electronic resources for knowledge
management and to improve health as literature was printed and sent home with the
patient and her grandmother as a reference for continued care.
 References

Fair Health Consumer [Internet] (2016a). Complete blood count. Retrieved

from:http//fairhealthconsumer.org/medical_costphp

Fair Health Consumer [Internet] (2016b). Complete metabolic panel. Retrieved

from:http//fairhealthconsumer.org/medical_costphp

Fair Health Consumer [Internet] (2016c). Thyroid stimulating hormone Retrieved

from:http//fairhealthconsumer.org/medical_costphp

Fair Health Consumer [Internet] (2016d). Thyroxine-Assay of free thyroxine. Retrieved

from:http//fairhealthconsumer.org/medical_costphp

Fair Health Consumer [Internet] (2016e). Urinalysis Retrieved

from:http//fairhealthconsumer.org/medical_costphp

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

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

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

Kauschinger, E.D., & Sandlberg-Cook, J. (2017). Routeine health screenings and immunizations.

In T.M. Buttaro, J. Trybulski, P. Polgar-Bailey, &J.Sandberg-Cook (Eds.), Primary Care:

A Collaborative Practice (5th ed.), (ppl. 145-163). St/ Louis, MO; Elsevier.

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

(2012). Nurse practitioner core competencies. The National Organization of Nurse

Practitioner Faculties. Retrieved from:

http://cymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecompetenc

iesfinal2012.pdf