Soap Hypertension and Depressive Disorder

  
SOAP NOTE SAMPLE FORMAT FOR MRC
  
Name:  LP

Date: 

Time: 1315
 

Age: 30

Sex: F
 
SUBJECTIVE
 
CC:  
“I am having vaginal itching and pain in   my lower abdomen.”
 
HPI:  
Pt is a   30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after   unsuccessful self-treatment of vaginal itching, burning upon urination, and   lower abdominal pain. She is concerned   for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with   urination has been present for 3 weeks, and the abdominal pain has been   intermittent since months ago. Pt has   tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms,   including urgency or frequency. She   describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10   at times. 200mg of PO Advil PRN   reduces the pain to a 7/10. Pt denies   any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but   denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any   vaginal irritants. She reports that   she is in a stable sexual relationship, and denies any new sexual partners in   the last 90 days. She denies any   recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well   as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also   takes Advil for. She reports her last   PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP   smear result. Pt denies any hx of   pregnancies. Other medical hx includes   GERD. She reports that she has an Rx   for Protonix, but she does not take it every day. Her family hx includes the presence of DM   and HTN. 
 
Current Medications: 
Protonix   40mg PO Daily for GERD
MTV OTC   PO Daily
Advil   200mg OTC PO PRN for pain
 
PMHx:
Allergies:  
NKA & NKDA
Medication Intolerances: 
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
 
Family History
Father-   DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal   grandparents without known medical issues; 1 brother and 3 other sisters   without known medical issues; No children.
 
Social History
Lives   alone. Currently in a stable sexual   relationship with one man. Works for   DEFACS. Reports occasional alcohol   use, but denies tobacco or illicit drug use.
 
ROS
 
General 
Denies   weight change, fatigue, fever, night sweats

Cardiovascular
Denies   chest pain and edema. Reports rare palpitations that are relieved by drinking   water
 
Skin
Denies   any wounds, rashes, bruising, bleeding or skin discolorations, any changes in   lesions

Respiratory
Denies   cough. Reports dyspnea that accompanies the rare palpitations and is also   relieved by drinking water
 
Eyes
Denies corrective   lenses, blurring, visual changes of any kind

Gastrointestinal
Abdominal   pain (see HPI) and Hx of GERD. Denies   N/V/D, constipation, appetite changes
 
Ears
Denies   Ear pain, hearing loss, ringing in ears

Genitourinary/Gynecological
Reports   burning with urination, but denies frequency or urgency. Contraceptive and STD prevention includes   condoms with every coital event. Current stable sexual relationship with one man. Denies known historic or recent STD   exposure. Last PAP was 7/2016 and normal. Regular monthly menstrual cycle   lasting 3-4 days. 
 
Nose/Mouth/Throat
Denies   sinus problems, dysphagia, nose bleeds or discharge

Musculoskeletal
Denies   back pain, joint swelling, stiffness or pain
 
Breast
Denies   SBE

Neurological
Denies   syncope, seizures, paralysis, weakness
 
Heme/Lymph/Endo
Denies   bruising, night sweats, swollen glands

Psychiatric
Denies   depression, anxiety, sleeping difficulties
 
OBJECTIVE
 
Weight   140lb 

Temp -97.7

BP 123/82
 
Height 5’4”

Pulse 74

Respiration 18
 
General Appearance
Healthy   appearing adult female in no acute distress. Alert and oriented; answers   questions appropriately. 
 
Skin
Skin is   normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions   noted.
 
HEENT
Head is   norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in   good repair.
 
Cardiovascular
S1, S2   with regular rate and rhythm. No extra heart sounds. 
 
Respiratory
Symmetric   chest walls. Respirations regular and easy; lungs clear to auscultation   bilaterally.
 
Gastrointestinal
Abdomen   flat; BS active in all 4 quadrants. Abdomen soft, suprapubic   tender. No hepatosplenomegaly.  
    
Genitourinary
Suprapubic   tenderness noted. Skin color normal   for ethnicity. Irritation noted at   labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes   not palpable. Vagina pink and moist   without lesions. Discharge minimal,   thick, dark red, no odor. Cervix pink   without lesions. No CMT. Uterus normal size, shape, and consistency.  
 
Musculoskeletal
Full   ROM seen in all 4 extremities as patient moved about the exam room.
 
Neurological 
Speech   clear. Good tone. Posture erect. Balance stable; gait normal.
 
Psychiatric
Alert   and oriented. Dressed in clean clothes. Maintains eye contact. Answers   questions appropriately.
 
Lab Tests
Urinalysis   – blood noted (pt. on menstrual period), but results negative for infection
Urine   culture testing unavailable
Wet   prep – inconclusive 
STD   testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B   & C 
 
Special Tests- No ordered at this   time.
 
Diagnosis 
 
Differential Diagnoses

1-Bacterial Vaginosis (N76.0)
2- Malignant neoplasm of female genital organ,         unspecified. (C57.9)
3-Gonococcal infection, unspecified. (A54.9)

Diagnosis
o Urinary   tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina.   (B37.3) secondary to presenting symptoms (Colgan & Williams, 2011) &   (Hainer & Gibson, 2011). 
 
Plan/Therapeutics
 

Plan:  

Medication – 

§ Terconazole cream 1 vaginal application QHS for 7 days for   Vulvovaginal Candidiasis; 
§ Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days   for UTI (Woo & Wynne, 2012)

Education – 

§ Medications prescribed. 
§ UTI and Candidiasis symptoms, causes, risks, treatment,   prevention. Reasons to seek emergent care, including N/V, fever, or back   pain. 
§ STD risks and preventions. 
§ Ulcer prevention, including taking Protonix as prescribed,   not exceeding the recommended dose limit of NSAIDs, and not taking NSAIDs on   an empty stomach. 

Follow-up         – 

§ Pt will be contacted with results of STD studies. 
§ Return to clinic when finished the period for perform   pap-smear or if symptoms do not resolve with prescribed TX.
            

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