Case Scenario 1- Complete the chart and answer the case scenario
Diagnosis
Definition
Presentation/
Management
Sign and Symptom
Bartholin Cyst
Squamous
Carcinoma of the
Vagina
Adenocarcinoma of
the Vagina
Lichen Sclerosus
Lichen Planus
Lichen Simplex
Chronicus
Vulvodynia
Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is usually worse just prior to and during the first two days of her menses. The pain is sometimes so severe that she has fainted. She states that defecation can cause severe pain and she therefore frequently becomes constipated. She often must miss work when experiencing the severe pain. Her
periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is 23.9 and her VS are all WNL. She is G0 P0.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other social history questions should you ask?
d. What other family history questions should you ask?
2. Objective:
a. Write a detailed focused physical assessment on this patient.
b. Explain what test(s) you will order and perform, and discuss your
rationale for ordering and performing each test.
3. Assessment/ Diagnosis:
a. What is your presumptive diagnosis? Why?
b. Any other diagnosis or differential diagnosis you would like to add?
4. Plan:
a. How will you manage this patient? What treatment or medication
would you prescribe and why?
b. Explain treatment guidelines and side effects including any possible
side effects of the medication and treatment(s),
c. What patient education is important to include for this patient?
(Consider including pharmacological, supplements, and non
pharmacological recommendations and education)
d. What is the follow-up plan of care?
e. Explain complications that can occur if patient does not comply with
treatment regimen.
Please refer to evidence-based guidelines to support your decision-making.
Adult Gero SOAP Note Template
Use this template for Comprehensive Notes (Initial Comprehensive/
Annual visit) and Problem-Focused Notes (Episodic/progress notes).
For the Problem-Focused Notes, only include pertinent problemfocused information related to the chief concern (CC).
Demographic Data
o
Patient age and gender identity
o
MUST BE HIPAA compliant
Subjective
Chief Complaint (CC)
o
o
o
Place the complaint in Quotes
Brief description -only a few words and in the patients words
Example: My chest hurts, I cannot breath, or I passed
out, etc.
History of Present Illness (HPI) the reason for the
appointment today
Use the OLDCARTS acronym to document the eight elements
of a chief concern (CC): Onset, Location/
radiation, Duration, Character, Aggravating factors, Relieving
factors, Timing, and Severity
o Briefly describe the general state of health prior to the
problem.
o
PAST MEDICAL HISTORY:
o List current and past medical diagnoses (in list format)
PAST SURGICAL HISTORY:
o List all past surgeries including dates (in list format)
FAMILY HISTORY:
o Include medical/psychiatric problems to include 2 generations
(parents, grandparents, siblings, or direct relatives (in list
format).
CURRENT MEDICATIONS:
o Include current prescription(s), over-the-counter medications,
herbal/alternative medications as well as vitamin/supplement
use.
o Include Name of medication, Dosage, Route, frequency.
ALLERGIES:
o Include medications, foods, and chemicals such as latex.
o Include reaction type in parenthesis.
o Example: Penicillin (Hives)
IMMUNIZATIONS HISTORY: list current immunization status and
address deficiency
HEALTH MAINTENANCE: (See Table below – Appendix A)
o List any age appropriate health maintenance due/
recommended in list format.
SOCIAL HISTORY:
An acronym that may be used here is HEADSS which stands
for Home and Environment; Education, Employment, Eating;
Activities; Drugs/Alcohol; Sexuality.
o Employment/Education should include: occupation
(type), exposure to harmful agents, highest school
achievement
o
REVIEW OF SYSTEMS:
o A ROS is a question-seeking inventory by body systems to
identify signs and/or symptoms that the patient may be
experiencing or has experienced that may or may not
correlate with the CC.
*If a + finding is found not related to the cc this may
represent an additional problem that will need to be detailed
in the HPI.
o Must include any physical complaint(s) by the body system
that is relevant to the treatment and management of the
current concern(s). List only the pertinent body systems
specific to the CC.
o Remember to include pertinent positive and negative findings
when detailing the ROS related to a chief concern (cc).
o Pertinent positives should be documented first.
o Do not repeat the information provided in HPI
o Documented as Reports or Denies
Example of an exemplary negative ROS for a Comprehensive
Note.
General: Denies malaise, weakness, fever, or chills. Denies recent
weight gains or losses of >20 pounds over the last 6 months.
Eyes: Denies change in vision or loss of vision, eye pain, sensitivity, or
discharge.
Ears, nose, mouth & throat: Denies ear pain, loss of or decreased
hearing, ringing of the ears, drainage from the ears. Denies change in
sense of smell, nose bleeds, sinus or facial pain, speaking problems,
hoarseness or choking, dry mouth, dental problems, or difficulty
chewing or swallowing.
Cardiovascular: Denies chest discomfort, heaviness, or tightness.
Denies abnormal heartbeat or palpitations. Denies shortness of breath,
denies having to sleep elevated on 2 pillows or more, no swelling of
the feet, no passing out or nearly passing out. Denies history of heart
attack or heart failure.
Respiratory: Denies cough, phlegm production, coughing up blood,
wheezing, sleep apnea, exposure to inhaled substances in the
workplace or home, no known exposure to TB or travel outside the
country. Denies history of asthma, COPD/emphysema or any other
chronic pulmonary disease.
Gastrointestinal: Denies nausea, vomiting, abdominal discomfort/pain.
Denies diarrhea, constipation, blood in the stool or black stools. Denies
hemorrhoids, trouble swallowing, heartburn or food intolerance. Denies
history of liver or gallbladder disease. No recent weight gains or losses
of > 20 pounds within the last year.
Skin & Breasts: Denies rash, itching, abnormal skin, or recent injury.
Denies breast pain, discharge, or other abnormality was reported by
the patient.
Musculoskeletal: Denies muscle or joint pain, back or neck pain, and
denies recent accidents or injuries. Denies physical disability or
condition that limits activity or ADLs.
Allergic: Denies history of seasonal allergies, allergic rhinitis, watery
eyes, or wheezing. Denies history of HIV, hepatitis, shingles, or
recurrent infections
Immunologic: Denies history of HIV, TB, hepatitis, shingles, or other
recurrent infectious diseases. Denies history of cancer – radiation or
chemotherapy.
Endocrine: Denies polyuria, polydipsia, and polyphagia. Denies history
of blood sugar instability. Denies temperature intolerance to hot or
cold. Denies swelling of the neck or nodules.
Hematopoietic/Lymphatic: Denies unusual lumps or masses. Denies
bruising quickly or bleeding easily. Denies history of anemia or recent
blood transfusions. Denies sickle cell disease or trait. Denies blood
dyscrasias.
Genitourinary: Denies dysuria, frequency, or urgency. Denies abnormal
vaginal/penile discharge or bleeding. Denies recent history of bladder
or kidney infections/stones. Denies sexual dysfunction or concerns.
Neurological: Denies unusual headaches, history of head injury or loss
of consciousness, lightheadedness, dizziness, vertigo. Denies
numbness of a body part or weakness on one side of the body. Denies
pins and needle sensation, abnormal movements, or seizure disorder.
Denies previous strokes, seizures or neurological disorders.
Psychiatric/Mental Status: Denies history of depression or anxiety.
Denies difficulty sleeping, persistent thoughts or worries, decrease in
sexual desire, abnormal thoughts, visual or auditory hallucinations.
Denies history of psychosis or schizophrenia. Denies difficulty
concentrating or change in memory.
Objective
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure. Heart rate. Respirations. SaO2 (on room
air or O2). Temperature. Weight. Height. BMI.
Example of exemplar PE for a Comprehensive Note with no
abnormal findings.
CONSTITUTIONAL/GENERAL APPEARANCE: Vital signs stable, in no acute
distress. Alert, well developed, well nourished.
HEENT:
Head: Atraumatic, normocephalic.
Eyes: Sclerae were white. Conjunctivae and lashes were clear. No lid
lag. Extraocular movements were intact (EOMI). PERRLA.
ENT: Ears, nose, mouth, and throat: Mucous membranes were pink,
moist and intact. External ear canals were clear without cerumen. TMs
were clear, pearly gray with good light reflex bilaterally. Hearing was
intact to whisper. Nares patent and mucosa is pink, moist and intact.
Mouth, lips and tongue, gums were intact with no lesions. Good dentition.
Hard and soft palates intact. Tongue and uvula midline.
NECK:
Supple. No JVD, thyromegaly or lymphadenopathy.
RESPIRATORY/CHEST: Unlabored. Chest rise is equal and symmetric.
Lungs are CTA bilaterally with no adventitious breath sounds.
CARDIOVASCULAR: S1, S2 without murmurs, rubs or gallops
appreciated.
BREASTS: Skin intact without lesions, masses, or rashes. No nipple
discharge. Breasts with slight asymmetry, no dimpling, retractions or
peau dorange appearance.
GI: Normoactive bowel sounds. No hepatosplenomegaly on exam. No
tenderness, masses, or hernias appreciated.
GENITAL/RECTAL: no suprapubic tenderness or bladder bulges. No
lesions, rashes, masses or swelling.
LYMPH NODES: No enlarged glands of the neck, axilla or groin.
MUSCULOSKELETAL: Gait and station were within normal limits. Full
range of motion in all joints. Muscle strength and tone were 5/5 all
groups. Equal arm swing.
INTEGUMENTARY: Skin was warm and intact. No rashes, lesions, masses
or discoloration. No abnormalities to fingers or toenails noted.
EXTREMITIES: No cyanosis or clubbing. No edema of the extremities.
Pulses +2 bilaterally radial and pedal.
NEURO: Cranial nerves are intact grossly, II-XII. DTRs intact, +2
bilaterally with symmetric response. Sensation intact to light touch. No
motor or sensory deficits.
PSYCH: A&O x3. Recent and remote memory intact. Mood and affect
appropriate during visit. Judgment and insight were within normal limits
at the time of visit.
*Full mini-mental status exam may be indicated based on the CC or
findings in the ROS or physical exam.
Assessment (Diagnosis)
Differential Diagnosis (DDx)
o
Include two (2) differential diagnoses you considered but did
not select as the final diagnosis. Why were these 2 diagnoses
not selected? Support with pertinent positive and negative
findings for each differential with an evidence-based
guideline(s) (required).
Working or Final Diagnosis:
o Final or working diagnosis (1) (including ICD-10 code)
o Provide a rational explanation supported by evidenced-based
guidelines (required). List the pertinent positive and negative
symptoms/signs that support your final diagnosis.
Plan
Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic
Diagnostics. Any labs, imaging, ordered? Remember you are
managing this patient in the outpatient/clinic setting, not the
hospital.
o Pharmacologic -include full prescribing information for each
medication(s) ordered. Name of Medication, Dosage, Route,
Frequency, Duration, number of tabs prescribed, number of
refills.
o
Patient Education:
o include specific education related to each medication
prescribed.
o Was risk versus benefit of current treatment plan addressed
for medication(s) and interventions? Was the patient included
in the medical decision making and in agreement with the
final plan?
o
NPs should not be prescribing non-FDA approved medications
or medications related to off-label use. If a physician
prescribed a non-FDA-approved medication for working
diagnosis or recommended off-label use, was education
provided and was the risk to benefit of the medication(s)
addressed in the patients education?
Referral/Follow-up
o When would you like the patient to be seen in clinic again. Did
you recommend follow-up with PCP, or other healthcare
professionals/specialists?
o When is the subsequent follow-up?
Reference(s)
o Include APA formatted references for written assignments.
o Minimum 2 references are required from evidence-based
resources.
APPENDIX A
Health Maintenance (Example not all-inclusive)
Preventive Care
Pap
Mammogram
A1C
Eye Exam
Monofilament Test
Urine
Microalbumin
Diet/Lifestyle Changes
Digital Rectal Exam (DRE)
PSA
Colonoscopy or FOBT
Dexa Scan
CXR
BNP
ECG
Echo
Stress
Test
Vaccines
The Prevention TaskForce (formerly ePSS) application assists primary care
clinicians to identify the screening, counseling, and preventive medication services
that are appropriate for their patients.
Download this app and be sure to reference when assessing Health Maintenance
priorities for your patients:
https://www.uspreventiveservicestaskforce.org/apps/
