King University MSN/NP Program

Clinical SOAP Note Format

Adult, Women, Geriatrics
Student: Megan Schleigh Course: NURS 5024: Seminar & Intensive Practicum

SOAP Note # 1
Pt. Initials: RH Age: 33 DOB: 8/24/86 LMP: 1/30/20
(S) CC: Here for a pap. Needs U/A repeated.
Pt. presents to clinic today for pap smear and repeat urinalysis d/t microscopic hematuria in U/A
on 1/7. Pt was recently seen in our clinic for complaints of dysmenorrhea. She is wanting to go
on birth control in hopes of decreasing menstrual cycle pain. She states that she has always had
painful periods but believes that they have been worsening the last six months. She describes the
pain the worst the first two days of her menstrual cycle, that is constant, and states that it is a
6/10 in her lower abdomen and lower back. She describes nausea and sometimes vomitting
during her menstrual cycle as well. She states that she often takes ibuprofen or Midol to help
with the pain. She has also been prescribed pain pills, does not recall the name, which she says
she took once and did not like the way it made her feel. She also states that she spends a lot of
time on a heating pad or in a bath during the start of her period to try to decrease pain. She denies
excessive bleeding. She denies current pregnancy. Denies wanting to get pregnant in the near
future as she has three young children. Pt denies history of abnormal pap, last pap 3 years ago
without HPV testing.

Medical Hx: Anxiety, Depression, Hyperlipidemia, GERD, Migraines

UTD on all immunizations. Pt received flu shot in office in October 2019. Tetanus in 2015. Pt
did not receive HPV series.
Surgical Hx: Hysteroscopy 2014
Social Hx: Pt is married with three young children, the youngest being two years old. She works
full time as a teacher. She denies drinking, smokining, or illegal drug use.
Family Hx: Mother: Anxiety, Cervical Cancer Father: CHF

Meds:
Buspirone Hcl 7.5 mg q12h PRN
Escitalopram 10 mg QD
Omeprazole 40 mg QD
Sumatriptan 25mg q2h PRN, maximum 8 tablets daily
Topiramate 25 mg BID
Allergies: Pt has a drug allergy to levaquin (feels as if her skin is burning and causes memory
problems). No known environmental, food or latex allergy.
ROS:

General: Denies fever, chills, nausea, or fatigue. Not feeling poorly.

HEENT: Denies congestion. Denies ear pain. Denies visual changes. Denies headaches. Denies
sore throat.

Skin: Denies skin irritation, rash, or concerning skin lesions. Denies bruising or bleeding easily.

Respiratory: Denies shortness of breath, wheezing, coughing, sputum production.

Cardio: Denies chest pain or heart palpitations, weakness, or passing out
GI: Denies current abdominal pain. Denies heartburn, nausea, diarrhea or constipation. Last BM
was earlier this morning.
GU: Complains of painful periods with pelvic pain. Denies of increased frequency or burning
with urination. Denies foul odor or hematuria. Denies incontinence.

Diet: Regular. Tries to limit fatty and high-sugar foods. High intake of fruits and vegetables.
Tries to eat a lot of fish as she has been told she has high cholesterol
Endocrine: Denies sleeping problems. Denies heat or cold intolerance. Denies any recent
weight gain or loss. Denies feeling tired.
MS: Denies painful joints,difficulty or pain with movement. Denies weakness in extremities.

Neuro: Denies dizziness, headache, or confusion

Psych: Admits to depression and anxiety, but that both have been well controlled. Takes lexapro
daily and buspar as needed- which she states both help a lot to decrease her symptoms. Denies
suicidal or homicidal ideation.

(O)
Vital signs: T: 98.3 P: 62 R: 16 BP: 122/64 HT: 5’ 5’’ WT: 159 lbs 8 oz BMI: 26.54 Pain: 0/10
Constitutional: Patient is pleasant, and alert and oriented x3. Patient is cooperative and answers
all questions appropriately. Pt. is in no acute distress.

HEENT: Head: Normocephalic. Hair is medium-length, brown, clean in ponytail.

Eyes: PERRLA bilaterally. Sclera is white in color with no erythema.

Ears: Not assessed

Nose: Not assessed

Mouth/teeth/gums: Not assessed

Throat/neck: Not assessed

Skin: Skin is warm, dry, and intact. No bruising, skin tears, lacerations, or erythema.

Respiratory: Respirations are even and unlabored, no increased work of breathing. Lung sounds
are clear in all lung fields. No wheezing, rhonchi, or crackles.

Cardio: Heart rate is regular. Rhythm is regular. No murmur or extra heart sounds heard upon
auscultation. No edema in upper or lower extremities. No jugular vein distention or bruit heard
over carotid artery.

GI: Abdomen is soft, non-distended, and non-tender. Bowel sounds normo-active in all four
quadrants. No visible pulsations noted. No masses observed during palpation.

External genitalia and vagina: Normal external genitalia, no significant vaginal lesions or
discharge.

Urethra: Normal, no bulging, erythema, or discharge

Bladder: Non-distended, non-tender

Cervix: Normal, no lesions. A pap smear was performed. Moderate amount of white mucous
present. Non-friable.

Uterus: Normal size, no tenderness, no masses

Adnexa: Normal, no masses or tenderness

Endocrine: No changes in weight.

MS: Steady gait, expected strength in extremities.

Neuro: Alert and oriented to person, place, and time. Normal judgment and insight.
Psych: Patient is engaged and is making eye contact. Answers all questions appropriately. Does
not appear to be depressed or anxious. Normal mood and affect.

(A)
Dx: Primary dysmenorrhea, N94.4

Abnormal urinalysis, R82.90

 Screening for cervical cancer, Z12.4

Birth control counseling, Z30.0

Differentials:
Secondary dysmemorrhea, N94.5

(ICD10data, 2020)
(P)

Primary dysmenorrhea: Performed pap smear today- no acute findings during examination to
cause dysmenorrhea, likely hormonal. Will initiate birth control therapy.

Abnormal urinalysis: Pt no longer has microscopic hematuria. Urinalysis completed today

negative for blood, nitrates, leukocytes, protein, glucose, or ketones.

Screening for cervical cancer: Pap smear completed today. No acute findings during
examination. Will order HPV testing with pap. Pts mother does have history of cervical cancer.
Return to clinic in 5 years if pap with HPV is negative, or sooner if needed.

Birth control counseling: Urine pregnancy test was compelted today, negative. Will order
Ortho Tri-Cyclen Lo, 0.18mg, to be taken daily. Encouraged pt to start to take on the first day of
menses. Instructed pt that birth control may cause spot bleeding. May increase migraines.

Anxiety: Stable. Continue to take lexapro daily and buspar as needed.

Depression: Well controlled. Continue to take lexapro daily and buspar as needed.

Hyperlipidemia: Pt not currently being medicatated for hyperlipidemia. Seems to be controlled

with diet and exercise. Pt is due for a lipid screening next year. Encouraged pt to continue
physical activity, and well-balanced diet, carb and fat conscious.

GERD: Well controlled. Continue nexium daily. Avoid dietary triggers.

Migraines: Well controlled. Continue topamax daily and sumitriptan PRN.

Follow-up instructions: Will call with pap smear results. Return back to clinic if pt develops
undesirable symptoms after contraceptive use or if dysmenorrhea does not improve or worsens.
Return to clinic in 3 months for scheduled appointment with physician or sooner if needed.
Discuss how you addressed at least 3 NONPF competencies during this visit.

1) Management of Patient Illness

2) Health Promotion/Health Protection and Disease Prevention

3) Communicates Practice Knowledge Effectively, Both Orally and in Writing

(NONPF, 2017)

This week, I was able to analyze and interpret the patient’s presenting symptoms and physical
findings to develop an appropriate diagnosis. I was also able to differentiate between normal and
abnormal findings during my exam. Once dysmenorrhea was my diagnosis, I followed guidelines
and performed a pap smear, which revealed no acute findings, leading me to primary
dysmenorrhea. I prescribed an oral contraceptive that I believed would help decrease her
dysmenorrhea but not cause her migraines to be uncontrolled. I also educated my patient on
potential side effects of birth control therapy.

This week I was able to see and chart on the entire schedule by myself. I was able to fully assess
my patients and came up with an appropriate diagnosis and treatment plan. I was able to
communicate my findings and recommendations to both my patient and my preceptor.

'
 References

ICD10data. (2020). 2020 ICD-10-CM Codes. Retrieved from https://www.icd10data.com/

ICD10CM/Codes

The National Organization of Nurse Practitioner Faculties [NONPF]. (2017). Nurse practitione

rcore competencies content. Retrieved from https://cdn.ymaws.com/www.nonpf.org/reso

urce/resmgr/competencies/2017_NPCoreComps_with_Curric.pdf

urce/resmgr/competencies/2017_NPCoreComps_with_Curric.pdf