SOAP Note <12 Month

 

Wellness Visit for a child less than 12 months old including specific vitals and measurements.

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Requirements:

3 APA references within the last 5 years

 

United States University

Student name

FNP 592: Common Illnesses Across the Lifespan

Instructor

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOAP

 

SUBJECTIVE:

ID:

CC:

HISTORY OF PRESENT ILLNESS (HPI):

PAST MEDICAL HISTORY:

PAST MEDICAL PROCEDURES:

MEDICATIONS:

ALLERGIES:

FAMILY HISTORY:

Mom:

Dad:

Brother:

Sister:

Paternal grandpa:

Paternal grandma:

Maternal grandpa:

Maternal grandma:

SOCIAL HISTORY:

-SEXUAL/REPRODUCTIVE:

-TOBACCO USE/Vaping:

-ALCOHOL USE:

-DRUG USE:

-MARITAL HISTORY:

-OCCUPATION:

-EXERCISE/DIET:

-SLEEP/STRESS:

-HOUSING:

-SAFETY:

IMMUNIZATIONS:

SPIRITUAL:

SUICIDE/DEPRESSION:

 

ROS:

CONSTITUTIONAL:

INTEGUMENTARY:

HEAD, EYES, EARS, NOSE, THROAT:

RESPIRATORY:

NECK:

CARDIOVASCULAR:

GASTROINTESTINAL:

PERIPHERAL VASCULAR:

GENITOURINARY:

MUSCULOSKELETAL:

PSYCH:

NEURO:

HEMATOLOGIC:

ENDOCRINE:

ALLERGY/IMMUNOLOGY:

 

OBJECTIVE:

VITAL SIGNS:

P: BP: RR: T: SpO2 RA: Pain:

Ht: Wt: BMI:

 

PHYSICAL EXAM:

GENERAL survey:

HEENT:

NECK:

CHEST/BREAST:

RESPIRATORY:

CARDIOVASCULAR:

ABDOMEN/GI:

GASTROURINARY:

LYMPHATIC:

MUSCULOSKELETAL:

NEUROLOGIC:

PSYCHIATRIC:

SKIN:

PERIPHERAL VASCULAR:

ASSESSMENT:

1.

2.

3.

Final diagnosis:

PLAN:

Diagnostic labs:

Treatment/Therapeutic Plan (meds):

Education & F/U plan:

Referrals:

 

 

 

 

References

1.

2.

3

SOAP Note

 

United States University

FNP 592: Common Illnesses Across the Lifespan

Teacher

Student

July 13th, 2022

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOAP Note Week Two

 

ID: Ms. Castaneda (MD) is a pleasant, 58-year-old, Hispanic female in no acute distress presents to the clinic. MD appears to be a reliable historian and reports she drove herself to the clinic.

CC:

HISTORY OF PRESENT ILLNESS (HPI): denies current complaints and any changes to her health. Denies recent illness, fever, SOB, dizziness, and headache.

PAST MEDICAL HISTORY:

PAST MEDICAL PROCEDURES:

MEDICATIONS:

ALLERGIES:

FAMILY HISTORY:

Mom: Deceased at age 73 with MI. Hx of HTN

Dad: Deceased at 77 from stroke. Hx of HTN.

Paternal grandpa: Unknown

Paternal grandma: Unknown

Maternal grandpa: Deceased at 76 from unknown causes. No health problems.

Maternal grandma: Deceased at 76 from car accident. Hx of HTN.

SOCIAL HISTORY:

-SEXUAL/REPRODUCTIVE: Heterosexual. Has 4 living children. Denies birth control and being sexually active.

-TOBACCO USE/Vaping: Never a smoker

-ALCOHOL USE: One drink per week with friends

-DRUG USE: Denies use or experimentation.

-MARITAL HISTORY: Single

-OCCUPATION: Waitress at local restaurant

-EXERCISE/DIET: Reports eating predominantly Mexican food for all three meals a day. Reports walking around the block every evening for exercise.

-SLEEP/STRESS: Denies stress pertaining to home conditions, finances, and safety. Reports sleeping 6-7 hours of uninterrupted sleep per night.

-HOUSING: Lives with oldest daughter, Maria, in a nonsmoking single-family home with no pets and 3 grandchildren.

-HOBBIES:

-SAFETY: Reports using seatbelt while driving. Denies texting-and-driving, having guns in the home, and participating in risky behavior.

IMMUNIZATIONS: UTD on childhood immunizations. Received J&J COVID vaccine 3/23/2021, and Pfizer booster 2/1/22. Last flu 2/1/22, and Tdap on 2/28/19.

SPIRITUAL: Catholic, attends St. Mary’s Catholic Church

SUICIDE/DEPRESSION: Denies depression, SI/SA, and anxiety. Reports satisfaction with life.

 

ROS:

CONSTITUTIONAL: Denies changes in weight, increased fatigue, and diaphoresis.

EENT/MOUTH: Denies sinus pressure or pain. Denies eye itching, discharge, and photophobia. Reports last eye exam was 1/1/22 with no abnormal findings. Denies ear discharge, ear pain, and trouble hearing. Last hearing exam was 1/1/22 with normal results. Denies nosebleeds and rhinorrhea. Denies trouble swallowing or throat pain. Denies sore throat and difficulty swallowing,

CARDIOVASCULAR: Denies palpitations and chest pain.

RESPIRATORY: Denies chest tightness, choking, and cough.

GASTROINTESTINAL: Reports daily BM. Denies abdominal distention, pain, and blood in stool.

GENITOURINARY: Denies difficulty urinating, dysuria, and enuresis.

MUSCULOSKELETAL: Denies gait problems, back pain, and limited ROM.

SKIN/BREAST: Denies changes in skin color, rash, or open wounds.

 

NEUROLOGIC: Denies dizziness, facial asymmetry, and H/A.

PSYCHIATRIC: Denies agitation, confusion, and SI.

ENDOCRINE: Denies polyuria, polydipsia, and polydipsia.

HEMATOLOGIC/ LYMPHATIC: Denies bruising or bleeding easily.

ALLERGY/IMMUNOLOGY: Denies being immunocompromised. Reports lactose allergy.

 

VITAL SIGNS:

P: 75 BP: 122/78 RR: 18 T: 97 F Oral SpO2 RA: 97 Pain: 0/10

Ht: 5’4 Wt: 161 lbs BMI: 25.99

 

PHYSICAL EXAM:

GENERAL survey: MD is alert-and-oriented x 4 and is seated upright on the exam table with a cloth drape draped over her lower body. She is a well-nourished, dressed, and groomed appropriately. She is acting appropriately and answering questions efficiently and quickly. Patient maintains eye contact throughout the visit. Patients’ daughter was on the phone during the examination for patient comfort.

HEENT: Head normocephalic. Bilat ears have normal TM with no bulging noted, ear canals are free of cerumen, and external ears without lesions or rashes. Nose is nontender, midline, and without drainage. Mouth is moist, dry, without lesions, erythema, or sores. Tonsils are without edema and exudate. Tongue is midline and pink. Sclera is white, eyelids are normal and not everted, EOM intact without nystagmus.

NECK: Supple, no signs of pain or limited ROM. Thyroid and trachea are midline.

CHEST/BREAST: Warm, dry, intact. No signs of jaundice, rash, or abrasions noted. No signs of obvious deformities. Bilat breasts are non-tender, and symmetrical and breasts are midline. No signs of mass, swelling, discharge, or inverted nipples.

RESPIRATORY: Normal rate, symmetrical. No signs of use of accessory muscles or respiratory distress. No adventitious breath sounds.

CARDIOVASCULAR: RRR. S1 and S2 present without murmurs, gallop, or rubs.

ABDOMEN/GI: Bowel sounds present in all 4-quadrants. No guarding or rebound tenderness upon palpitation. Soft, non-distended, and non-tender.

GASTROURINARY: Hair pattern is appropriate for age. There is no rash or excoriations. The clitoris is normal sized without lesions. Labia are without erythema, lesions, or masses. There is no discharge. Bartholin’s glands are non-tender without tenderness. Urethral meatus is without swelling, erythema, or prolapse. Urethra is without masses, tenderness, or scarring. The perineum without fistula or scarring. Uterus is anterior, midline, smooth, and not enlarged. There is no adnexal tenderness or ovarian tenderness to palpation. The introitus is normal with no vaginal vagina discharge. The vaginal mucosa is pink and smooth with no masses or lesions. No abnormal vaginal odor.

LYMPHATIC: Bilat UE and LE are non-palpable and non-tender.

MUSCULOSKELETAL: Full, painless ROM noted to UE and LE bilat. No signs of deformity, swelling, or tenderness. 5/5 strength noted UE and LE bilat.

NEUROLOGIC: No focal deficit. A&Ox4. Motor function, coordination, and gait is steady and smooth. Cranial nerves 1-12 are grossly intact.

PSYCHIATRIC: Normal mood, behavior, judgment, thought content, and speech.

SKIN: Normal for ethnicity with no signs of jaundice, lesions, or rash.

PERIPHERAL VASCULAR: Peripheral pulses present +2 noted to UE and LE bilat. No signs of clubbing or cyanosis.

 

ASSESSMENT:

1. Annual women’s health exam and encounter for gynecological examination without abnormal findings. ICD Code Z01.149

2. Rule out atypical glandular cells (AGC)

3. Rule out endocervical adenocarcinoma in situ (AIS)

4. Rule out adenocarcinoma

PLAN:

Diagnostic labs:

· Ordered Pap smear screening (Thin Prep Pap test)

· Sample acquired and sent to lab for analysis for screening for malignant neoplasm of cervix.

· ICD: Q0091- Screening Papanicolaou smear, obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory

Treatment/Therapeutic Plan (meds):

· Continue prescribed medications

· If abnormal, OB/GYN referral or repeat Pap in one year with the possibility of colposcopy and biopsy.

Education & F/U plan:

· Educate patient that there will be some mild cramping that can be relieved with OTC Ibuprofen.

· Advised she will be notified via phone call of the results.

· Encourage the patient to schedule an appointment for a mammogram.

· If results are normal, a repeat routine Pap smear will be performed in three years.

· Encouraged patient to call the clinic if she experiences any irregular bleeding.

· Advised patient to go to the ER if she experiences heavy bleeding that doesn’t resolve after 1-2 days or severe pelvic pain.

Referrals: If abnormal, refer to OB/GYN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Mayo Clinic’s advice on when to begin mammograms. (2019). Mayo Clinic. https://www.mayoclinic.org/tests-procedures/mammogram/expert-answers/mammogram-guidelines/faq-20057759

 

National Cancer Institute. (2019, February 6). HPV and Pap Testing. National Cancer Institute; Cancer.gov. https://www.cancer.gov/types/cervical/pap-hpv-testing-fact-sheet