UNIT 3 SOAP Note – Ms. A presents with complaints of headache and general fatigue

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Case: AA – Hypertension Stage 2 and Overweight

UNIT 3 SOAP Note – Ms. A presents with complaints of headache and general fatigue Scenario Description:

Ms. A presents with complaints of headache and general fatigue. She also reports that she has had periodic nosebleeds. She reported that she has been taking many medications for her hypertension in the past, but stopped taking them because of the side effects. She could not recall the names of the medications. Prescribed one year ago and currently taking 100 mg/day atenolol and 12.5 mg/day hydrochlorothiazide (HCTZ), which she admits to taking irregularly because “… they bother me, and I forget to renew my prescription.” Despite this antihypertensive regimen, her blood pressure remains elevated, ranging from 150 to 155/110 to 114 mm Hg. In addition, Ms. A admits that she has found it difficult to exercise, stop smoking, and change her eating habits. She has not seen her primary care doctor in a year. Smokes 15 cigarettes a day for 10 years.(Hypertension Stage 2 and Overweight)

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Here are 10 SOAP NOTE examples to help you do UNIT 3 SOAP Note – (Ms. A presents with complaints of headache and general fatigue) SOAP note

MSN SOAP Note Template

Name:

Pt. Encounter Number:

Date:

Age:

Sex:

SUBJECTIVE

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CC:

Reason given by the patient for seeking medical care “in quotes”

HPI:

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.(Hypertension Stage 2 and Overweight)

Struggling with your SOAP Note? here’s a comprehesive guide What is a SOAP Note? [Subjective, Objective, Assessment and Plan Examples]

Medications: (List with reason for med )

Allergies: (List with reaction)

Medication Intolerances:

Past Medical History:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”

Family History

Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?(Hypertension Stage 2 and Overweight)

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General

Weight change, fatigue, fever, chills, night sweats, and energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, and edema(Hypertension Stage 2 and Overweight)

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles

Respiratory (UNIT 3 SOAP Note – Ms. A presents with complaints of headache and general fatigue)

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB

Eyes

Corrective lenses, blurring, and visual changes of any kind(Hypertension Stage 2 and Overweight)

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools

Ears

Ear pain, hearing loss, ringing in ears, and discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDs

Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat(Hypertension Stage 2 and Overweight)

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain

Musculoskeletal (UNIT 3 SOAP Note – Ms. A presents with complaints of headache and general fatigue)

Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis

Breast

SBE, lumps, bumps, or changes

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells

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Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance (UNIT 3 SOAP Note – Ms. A presents with complaints of headache and general fatigue)

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx

OBJECTIVE

Weight BMI

Temp

BP

Height

Pulse

Resp

General Appearance

Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later.(Hypertension Stage 2 and Overweight)

Skin

Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted. (UNIT 3 SOAP Note – Ms. A presents with complaints of headache and general fatigue)

HEENT

Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. (UNIT 3 SOAP Note – Ms. A presents with complaints of headache and general fatigue)(Hypertension Stage 2 and Overweight)

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary

Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are nonpalpable. (UNIT 3 SOAP Note – Ms. A presents with complaints of headache and general fatigue)(Hypertension Stage 2 and Overweight)

(Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)

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(Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm).(Hypertension Stage 2 and Overweight)

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.(Hypertension Stage 2 and Overweight)

Lab Tests

Urinalysis—point of care test done today in the office- results positive for nitrites and blood, negative for leukocytes.

Urine culture collected in office—pending results, sent to lab (UNIT 3 SOAP Note – Ms. A presents with complaints of headache and general fatigue)

Wet prep collected in office—pending results, sent to lab.

Assessment

· Include at least three differential diagnoses

· Provide rationale for each differential diagnosis

· Final diagnosis

· Pathophysiology of primary and rationale for choosing as final

Plan

· Medications(Hypertension Stage 2 and Overweight)

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion

· Referrals

· Follow up

(Hypertension Stage 2 and Overweight)
UNIT 3 SOAP Note - Ms. A presents with complaints of headache and general fatigue 1

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Cathy, CS

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