soap note

Name: L.B

Date: 03/10/2020

Time: 09:00

Age: 44 y/o

Sex: F

SUBJECTIVE

CC: 

” I do not feel well around one week before my periods " 

HPI: 

L.B is 44 years-old female patient complaints of mood changes, breast tenderness, frontal headaches, lack of energy one to two weeks before her periods. She has been taking Acetaminophen but, the symptoms don’t improve. She has been problems with her normal activities. She has regular periods that last 5 days. Last PAP smear and mammogram on 03/2019 and normal. 

Medications:

Tylenol as needed for pain

Colace for constipation

PMH (include-immunization status including Gardisil, GTPLA).

Current or past illnesses: Headaches.

Immunizations: All vaccines updated except Gardasil.

Allergies:  N/A

Medication Intolerances: Naproxen.

Chronic Illnesses/Major traumas: None.

Hospitalizations/Surgeries (include delivery of pregnancies here)

Cholecystectomy

Pregnancy History: G2T1P0A1L1.

Family History

Mother: Alive 71 years. HTN.

Father: Alive 77 years. HTN.

Social History

Patient is married, lives with her husband and daughter in a house. Works as a secretary in a warehouse. Education level bachelor. Sexually active with her husband only. Denies drink coffee. Denies alcohol. Denies use of recreational drugs.

ROS (if you are seeing a patient for an Episodic OV – you may alter the ROS accordingly)

General

Denies weight’s changes. No fever or chills.

Cardiovascular

Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea. 

Skin

Normal appearances. Denied presences of moles, rash, or itching. Not change in nails/hair.

Respiratory

Denies dyspnea, hemoptysis, or pleuritic pains.

Eyes

Denies problems or changes in his vision; denies double or blurred vision. No redness or swelling. No scotomas or flashes. No discharge noted. 

Gastrointestinal

Denies hemorrhoids, constipation, or diarrhea. No variation in bowel habits. Denies nausea, vomiting, dysphagia, jaundice, belching or flatulence. 

Ears

Denies difficulty or changes in his hearing. Denies tinnitus, or discharges.

Genitourinary/Gynecological

Menarche 12years old. Reports LMP: 02/14/2020 lasted 5 days, normal flow. Last PAP 03/2019, normal. No history of STDs. No contraceptive method, husband has a vasectomy performed. Pregnancy History: G2T1P0A1L1. Denies dysuria, frequency or urgency. No vaginal discharge.

Nose/Mouth/Throat

Denies nosebleeds, nasal obstruction. No Bleeding gums, teeth or mouth pain, no lesion in mouth or tongue, no dry mouth, or excessive salivation. No sore throat.

Musculoskeletal

Denies joint stiffness, limitation of movement, no history of musculoskeletal or disk diseases; denies any muscle or joint pain.

Breast

Breast tenderness before her period. Denies alteration of nipples, or discharge. No lumps or masses. Last mammogram on 03/2019, normal.

Neurological

Positive for headaches before her period. Denies syncope or seizure. No dizziness or vertigo.

Heme/Lymph/Endo

Denies bruising or bleeding. No history of anemia, blood transfusions. Denies exposure to toxic agents or radiation. No HIV history.

Psychiatric Denies sadness, or anxiety. No sleeping problems.

OBJECTIVE - (if you are seeing a patient for an Episodic OV – PE should relate to the CC)

Weight: 159 lb.        BMI: 23.3

Temp: 97.8

BP: 116/68

Height: 5’7’’

Pulse: 88

Resp: 16

General Appearance: Patient is alert and oriented x 4. Well-developed and nourished, keeps a normal position and posture. She speaks clear and appropriate.

Skin

Intact, clean, moist. Well hydrated, no rashes or lesions.

HEENT

Normocephalic, symmetric. Eyes: Sclera white, conjunctiva pink. PERRLA. Ears: Bilateral canals patent. No exudate. Nose: External aspect is normal. Throat: Lips and oral cavity pink and moist. Tongue moist and pink. Tonsils bilateral, normal size, no exudate. No inflammation, or lesions. Neck: Thyroid with normal size, no nodules or masses.

Cardiovascular

S1, S2. Regular rate and rhythm, no murmurs, no gallops. No thrill or palpable murmurs on palpation. All peripheral pulses are present. No edema.

Respiratory

Lungs clear to auscultation bilaterally, normal respiratory effort. No rales, no rhonchi, no wheezes upon auscultation.

Gastrointestinal

Soft, no tenderness, no masses, Bowel sounds presents in all four quadrants. No ascites. No splenomegaly, no hepatomegaly.

Breast Breasts symmetric.

There is no axillary adenopathy or tenderness, no nipple discharge or retraction. No breast tissue retraction noted in any position. Upon palpation, there were no palpable lumps or bumps.

Genitourinary

No CVA tenderness. Genitalia: External genitalia normal appearance; skin color is consistent with general pigmentation. No vulvar lesions noted. Cervix with no discharge. No cervical motion, no tenderness. Bimanual examination: Mobil cervix, not painful. No adnexal masses or tenderness. Vaginal walls are smooth and pink, with normal rugae; no lesions noted. Ovaries are non-palpable.

Musculoskeletal

Normal gait and ROM. No joints and muscle tenderness, no warmth, no erythema or inflammation.

Neurological

Speech normal, no neurological focalizations, no sensory-perceptions disorders. No altered mental status.

Psychiatric

Alert and oriented. No signs or symptoms of depression, no anxiety, no suicidal ideas, maintains eye contact.

Lab Tests (list the results if you have them)

CBC

Pelvic and Transvaginal Sonogram.

TSH and thyroid function tests. 

Special Tests (done or ordered during the OV)

None

 Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used

Primary Diagnosis:

1-Premenstrual tension syndrome (N94.3): Premenstrual syndrome is characterized by cyclical physical and behavioral symptoms occurring in the luteal phase of the normal menstrual cycle. Physical symptoms are abdominal bloating, breast tenderness, and headaches.

Differential Diagnoses:

1-Depression (F32.8): Patient meets DSM-5 criteria for major depression. Depression symptoms include low mood, low energy, anhedonia, appetite change, sleep disturbance, difficulty concentrating, and thoughts of suicide.

2-Chronic fatigue, unspecified (R53.82): Chronic fatigue syndrome (CFS) is characterized by a sudden or gradual onset of persistent disabling fatigue, post exertional malaise, unrefreshing sleep, cognitive and autonomic dysfunction, myalgia, arthralgia, headache, sore throat and lymph nodes, with symptoms lasting at least 6 months.

3-Hypothyroidism, unspecified (E03.9): Hypothyroid symptoms and signs include weight gain, constipation, cold intolerance, depression, dry skin, and delayed deep tendon reflexes.

Plan/Therapeutics (explain fully)

Plan: 

Medication:

-Ibuprofen 800 mg 1 tab every 6-8 hours during her period taken with food, 2 refills (Epocrates, n.d).

No pharmacology treatment:

Lifestyle modification including exercise, relaxation, and cognitive behavioral therapy.

Education:

Patients is instructed in establishing and maintaining a daily low-impact physical activity routine (e.g., walking, stationary biking, stretching, and swimming). Graded exercise programs should be structured and monitored to prevent cycles of overexertion and prolonged inactivity. (Epocrates, n.d).

Follow up: In four weeks.

References

Buttaro, T. M. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, Mo.:

Mosby/Elsevier.

Codina, L. M., & Codina, L. M. (2014). Adult-gerontology nurse practitioner certification intensive review:

Fast facts and practice questions. New York: Springer Pub.

Domino, F. J., & Baldor, R. A. (2018). The 5-minute clinical consult 2018 (26th ed.).

Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Epocrates. (n.d.). Retrieved from https://online.epocrates.com/drugs/1153/fluoxetine

Epocrates. (n.d.). Retrieved from https://online.epocrates.com/drugs/233/ibuprofen

Family practice guidelines / [edited by] Jill C. Cash, Cheryl A. Glass. Four editions.

https//www.nursingknoledgecenter.org.