KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT

ADULT, WOMEN, GERIATRICS
Student: Susan Kelly Course: 5024

SOAP Note #2 Well Adult

Pt. Initials: M. B. Age: 32 DOB: 10/24/1984 LMP: 5/1/2018

(S)
CC: Establishing care as a new patient
HPI: Not pertinent to this exam
Character: Not pertinent to this exam
Onset: Not pertinent to this exam
Location: Not pertinent to this exam
Duration: Not pertinent to this exam
Severity: Not pertinent to this exam
Pattern: Not pertinent to this exam
Associated: Not pertinent to this exam
G 1, T 1, P 0, A 0, L 1
Medical Hx: No reports of medical issues
Surgical Hx: Denies surgical history
Social Hx: M. B. lives in a single-story ranch style home built in 2005 with her husband and 2-
year-old son. The home is equipped with smoke detectors and has an adequate amount of fire
extinguishers per the square footage as reported by M. B. M. B. reports she breastfed her son for
the first six weeks and then transitioned to bottle feeding prior to returning to work. M. B. is
currently employed at a local factory as a “line tech.” She reportedly enjoys her job and spending
time with her coworkers. M. B. reports a good friend, family and church family support system.
M. B. reports she and her family attend church on a regular basis where her husband serves as a
deacon. She reports the entire family is very active in church functions. M. B. reports she has
never drank alcohol or used tobacco products of any type, she also reports that she has never
used illicit drugs nor has she been exposed to anyone that has done so. M. B. reports “always”
wearing a seatbelt. M. B. reports her immunizations, dental, visual, and hearing exams are up to
date. M. B. reports her GYN exam is due in August of this year. M.B. reports she sees her
primary care at least yearly for a “check-up”. A release was signed to obtain past medical
records.

Family Hx: No reports of a family history of heart disease, hypertension, diabetes, or cancer. No
reports of a significant medical, surgical or social family history.

Meds/Allergies: NKA. No reports of current medications on a daily basis, but she does take
Motrin 200mg OTC as needed.

ROS: General: Reports of feeling “great” no reports of weakness, recent fever, chills,
unexplained weight loss or gain. Reports adequate sleep of 6 to 7 hours a night. Reports her
home, neighborhood and work as safe environments free of abuse and violence. Reports good
intimate relations with her spouse.
HEENT: No reports of changes in vision or hearing, tinnitus, nasal/sinus problems, hoarseness,
or dry mouth.

Skin: No reports of rashes, ecchymosis, purities, dryness, discolorations, changes in moles or

hair.

Respiratory: No reports of shortness of breath, coughing, wheezing, or snoring

Cardio: No reports of chest pain, palpitations, edema, swelling, or exertion with exercise or
activity.

GI: No reports of nausea, vomiting, diarrhea, constipation, abdominal pain, or discomfort.

Denies difficulty swallowing, chocking episodes, difficulity swallowing or rectal bleeding.

GU: No reports of polyuria, dysuria, anuria, hematuria, or incontinence. Last Papanicolaou

(PAP) was two years ago, reports normal results.

Diet: No recent dietary changes reported. Reports having an adequate intake of water 8 to 10
glasses a day. Reports having morning black coffee and 2% milk daily, 16 ounces. The majority
of the meals are home cooked baked not fried foods. Breakfast is oatmeal and toast or yogurt
with coffee and milk. Lunch is oven roasted turkey sandwich on whole wheat with vegetables
and ranch dressing water is her drink of choice. Dinner is typically white fish or chicken
occasionally beef with a starch, a vegetable, bread and fruit with cottage cheese. M. B. has a
snack prior to bed that usually consist of a glass of milk and crackers; occasionally she will have
popcorn. M.B. reports eating occasionally at a fast food restaurant such as McDonalds but does
not do it frequently.

Endocrine: No reports of heat or cold intolerance, diaphoresis, polyuria, polydipsia, or excessive

hunger.

MS: No reports of muscle, joint pain, weakness or stiffness. No reports of limited range of
motion, back or neck pain.

Neuro: No reports of headache, dizziness, weakness, numbness, tingling, burning, tremor, or

seizure activity.

Psych: No reports of anxiety, depression, suicidal or homicidal ideations.

(O)
Vital signs: T 98.6 P 80 R 22 BP 110/72 HT 5’6” WT 120 pounds BMI 19.36 Pain
0/10
Constitutional: Pleasant, well-mannered, well groomed, well-nourished Caucasian female.
Dressed appropriately for age and weather. Cooperative, made eye contact and answered
questions appropriately. No grimacing, fidgeting, or distress noted.
HEENT: Normocephalic, no infestations, flakes, abrasions, or raised areas noted on scalp,
eyebrows, eyelashes or facial area. Sclera white in color with no redness or irritation noted,
conjunctiva pink and moist. PERRL no nystagmus noted. Denies tenderness of pina or tragus
bilaterally, tympanic membrane visualized, bilateral pearly gray no drainage, bulging, redness, or
cerumen noted to outer canal or membrane. No obstruction noted to nasal passages, no redness,
sores, septal deviation, polyps or drainage. Lips pink and moist without sores or crustations. Oral
cavity pink and moist, no ulcerations, leukoplakia, or dental caries noted. All teeth are present.
Tongue midline adequate ROM, no glossitis, uvula midline, tonsils palpated non-tender,
visualized bilateral 2+. Trachea midline, thyroid palpated, no goiter or tenderness noted. Facial,
neck and cervical lymph nodes non-palpable, non-tender.
Skin: Pink, warm and dry to touch. No lacerations, abrasions, ulcerations, ecchymosis, erythema,
or rashes.

Respiratory: All lobes clear to auscultation bilaterally. No wheezing, crackles or rhonchi noted.
Cardio: S1 S2 RRR No gallops, rubs or murmurs noted. No JVD or bruits, no edema noted
bilateral upper and lower extremities.

GI: Abdomen non-tender non-distended bowel sounds positive times four quadrants.

GU: No bladder distension or CVA tenderness noted.

Endocrine: No exophthalmos, goiter, hirsutism or hyperhidrosis noted.

MS: Full ROM strength 5/5 bilateral upper and lower extremities, neck and back. No redness or
edema noted in joints.

Neuro: Alert and oriented times three. Steady gait and balance.

Psych: Appropriate affect answers all questions appropriately. Does not present anxious or
fidgets no depressed mood noted.

Other: Not applicable to this exam.

(A)
Dx: (include ICD 10 code - http://www.icd10data.com/ICD10CM/Codes ) (list as many
diagnoses as indicated)
Z00.00 Routine medical exam

Differentials:
1. Thyroid disorder E07.9
2. Binge eating F50.81
3. Malnutrition E45
 (P) (Include costs of tests, medications, etc. – can find resources for this at
http://www.nlm.nih.gov/services/drug_procedure_costs.html; www.epocrates.com,
http://www.goodrx.com)

TSH $75.00
Free T4 $49.00
UA $9.00
CBC $38.00
CMP $58.00
Lipid Panel $56.00

Prices are out of pocket without insurance

Pt. Education: Discussed the following:

Skin cancer preventative measures such as limiting sun exposure and the utilization of sun screen
Avoidance of tanning beds
Necessity of getting 30 minutes a day of physical activity
Need to get 7 to 8 hours sleep a night
Maintain a healthy weight
Avoid tobacco use and second-hand smoke
Utilization of seatbelts
Avoidance of texting/talking on the phone when driving
Changes breast undergo during the menstrual cycle, any lingering changes or noted
abnormalities should be reported.
Eye exam every two years or sooner if needed
Regular dental visits/cleanings
Patient was instructed to watch food labels for hidden calories and carbohydrates. Patient was
instructed to limit sugary drinks. Liquid kilocalories, such as strong satiety signaling properties
as solid foods, which can lead to greater kilocalorie ingestion throughout the day (Grantham,
2017).

Preventive Care: Discussed the importance of keeping her upcoming GYN appointment to screen
for cervical cancer and HPV. Report any changes in family history to facilitate an appropriate
plan of care for M.B. The need for yearly flu vaccines. Starting at age 50 women should have a
mammogram every two year. The importance of self-breast awareness.

Follow-up instructions: Follow-up PRN

Other: Not applicable to this exam
Discuss how you addressed at least 3 NONPF competencies during this visit. (See NONPF
competency list available at
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecompetenciesfina
l2012.pdf )

1.Independent Practice Competencies

An independent practice competency is met through health promotion, prevention, and

screenings (Thomas et al., 2014). This competency was met through health promotion and
prevention education along with reviewing social and family history.

2.Scientific Foundation Competency

According to Thomas et al. (2014), this competence is met through comparison of patient data
sets with evidence-based standards to improve care. This competency was met by evaluation of
the patient’s statistics such as vital signs, BMI, ROS, social and family history, medication
utilization, and physical examination. After gathering appropriate data, the development of an
individualized plan of care.

3.Technology and Information Literacy Competencies

According to Thomas et al. (2014) this competency is met through the use of technology in
clinical practice. This competency was met by utilizing electronic resources identifying current
evidence-based practice in the patient care setting.
Reference

Fair Health Consumer (2016a). Complete blood count. Retrieved

from:http//fairhealthconsumer.org/medical_costphp

Fair Health Consumer (2016b). Complete metabolic panel. Retrieved

from:http//fairhealthconsumer.org/medical_costphp

Fair Health Consumer (2016c). Thyroid stimulating hormone Retrieved

from:http//fairhealthconsumer.org/medical_costphp

Fair Health Consumer (2016d). Thyroxine-Assay of free thyroxine. Retrieved

from:http//fairhealthconsumer.org/medical_costphp

Fair Health Consumer (2016e). Urinalysis Retrieved

from:http//fairhealthconsumer.org/medical_costphp

Grantham, S. L. (2017). Obesity and weight management. In T. M. Buttaro, J. Trybulski, P.

Polgar-Bailey, & J. Sandlberg-Cook (Eds.), Primary Care: A Collaborative Practice (5th

ed), (pp.109-125). St. Louis, MO: Elsevier

Kauschinger, E. D., & Sandlberg-Cook, J. (2017). Routeine health screenings and

immunizations. In T. M. Buttaro, J. Trybulski, P. Polgar-Bailey, & J. Sandberg-Cook

(Eds.), Primary Care: A Collaborative Practice (5th ed.), (pp. 145-163). St/ Louis, MO;

Elsevier.

Steps for better health by age: Your 30s. (2018). Retrieved from

https://www.womenshealth.gov/nwhw/by-age/your-30s
Thomas, A. C., Crabtree, M. K., Delaney, K., Dumas, M. A., Kleinpell, R., Marfell, J. …Wolf,

A. (2012). Nurse practitioner core competencies. The National Organization of Nurse

Practitioner Faculties. Retrieved from:

http://cymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecompetenc

iesfinal2012.pdf