Soap Note
Student’s Name:
Institution:
Date
SOAP NOTE
| Name: Patient | 12/05/2020 | Time: 1:00 pm | ||
| Age: 16 | Sex: Female | |||
| SUBJECTIVE | ||||
| CC:
“Virginal bleeding”.
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| HPI:
The patient is a 16-year-old female with virginal bleeding. She is experiencing fatigue, nausea and vomiting with frequent urination. |
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| Medications:
No current or recent medications |
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| PMH
Allergies: There is no determined allergic substance. Medication Intolerances: Not any Hospitalizations/Surgeries Nil Other: Immunizations: all Vaccinations are up to date. Exercise and leisure: she goes for a run daily. Sleep: The patient gets asleep for 10 hours daily. Diet: No food selected eats well. Menstruation: last menstrual periods: 3/16/2020 |
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| Family History
Father –diabetic. No genetic disorders in the family (Bickley & Szilagyi, 2012). |
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| Social History: Do not smoke. | ||||
| ROS | ||||
| General
Weight gained |
Cardiovascular
No chest pain. |
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| Skin
No clubbing. |
Respiratory
She denies difficulty in breathing and cough. |
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| Eyes
No blurred vision. |
Gastrointestinal
Some abdominal pain. |
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| Ear
There are no pains in the ears.
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Genitourinary and Gynecological
The patient experiences Frequent urination. |
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| Nose/Mouth/Throat
Dry mouth. |
Musculoskeletal
Do not experience pain |
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| Breast
Tender breasts. There are lumps. |
Neurological
No weakness. Denies headache |
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| Heme/Lymph/Endo: denies blood cloth. | Psychiatric
No suicidal attempts. |
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| OBJECTIVE | ||||
| Weight 332 lbs BMI 52.51 | Temp 97.6 | BP 112/72 | ||
| Height 71 in | Pulse 70 | Respiration 17 | ||
| General Appearance
A 16-year old female presents herself for laboratory examination for pregnancy and STIs. |
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| Skin
The skin is dry and intact. |
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| HEENT
Head: no tenderness in palpitation(Löck et al., 2017) Eyes: The PERRLA is normal. Ears: They are clear. Nose: It is moist without drainage. Neck: No swollen lymph nodes, occipital nodes or enlarged thyroids. |
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| Cardiovascular
Murmurs noted. No edema. |
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| Respiratory
Regular. |
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| Gastrointestinal
Soft |
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| Breast
Breasts exhibit tenderness. No lumps |
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| Genitourinary
LMNP 3/16/2020 |
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| Musculoskeletal
No swellings. |
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| Neurological
Clear speech. Upright posture. |
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| Psychiatric: very active and always alert. | ||||
| Lab Tests :
Ultrasound Quantitative beta-human chorionic gonadotropin. CBC, wet mount preparation for trichomonas. BCR test for gonorrhea and chlamydia. Progesterone levels test.
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| Special Tests
Ectopic pregnancy. |
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| Diagnosis
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| Differential Diagnoses
o 1-spontaneous abortion o 2-idiopathic bleeding in a viable pregnancy. o 3-ectopic pregnancy o STIs- Chlamydia Presumptive Diagnosis o Chlamydia
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| Plan/Therapeutics | ||||
| o Plan:
§ Diagnosis: STI (Chlamydia) § Further testing-none § Medication: The patient to get a single dose of azithromycin § Education: patient to avoid any sexual activity for a week after taking the antibiotics. · Advise doing light exercise daily. · Advise to eat healthily and get food diary. · The patient to practice high hygiene levels. · If the conditions continue, the patient to return for further diagnosis (Goolsby & Grubbs, 2018). § A follow up for the patient for one month is done to ascertain if there is any complication and to ensure strict dosage. If the plan is not giving better results, a referral will be advised.
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| Evaluation of patient encounter | ||||
References
Bickley, L., & Szilagyi, P. G. (2012). Bates’ Pocket Guide to Physical Examination and History Taking. Lippincott Williams & Wilkins.
Goolsby, M. J., & Grubbs, L. (2018). Advanced assessment interpreting findings and formulating differential diagnoses. FA Davis.
Löck, S., Perrin, R., Seidlitz, A., Bandurska-Luque, A., Zschaeck, S., Zöphel, K., … & Troost, E. G. (2017). Residual tumour hypoxia in head-and-neck cancer patients undergoing primary radiochemotherapy, final results of a prospective trial on repeat FMISO-PET imaging. Radiotherapy and Oncology, 124(3), 533-540.