Assignment task:
Gabryela is 23-year-old Hispanic female who comes to the clinic for her annual wellness exam. She complains of painful menstrual cycles, acne and facial hair growth. She states her menstrual cycles started becoming painful about 5 months ago, but the acne and facial hair seemingly "appeared overnight". She states that she did shave last night, but the hair usually appears on her chin and along her jawline. Her menstrual cycle remains regular, with normal flow, with pain lasting throughout the cycle. She denies having any sexual partners and has not been sexually active for 3 years.
She is not on any current medications. She denies any past medical or surgical history. Both her maternal and paternal grandmothers have had breast cancer. She lives at home with both parents, and her two younger sisters. She is attending nursing school at Florida Atlantic University.
Vitals: Ht. 64 in, Wt. 155, BP. 112/64, P. 76, SPO2. 100%, Resp. 16, LMP- 6/11/24.
No allergies.
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the patient's own words, for instance,"headache,"not"bad headache for 3 days."
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start everyHPI with age, race, and gender (e.g., 34-year-old African Americanfemale). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was "headache," the LOCATESfor the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxenmakes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use.Also include over-the-counter (OTC) or homeopathic products.
Allergies:Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc& SubstanceHx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relativesshould be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment.Current concerns:(Anxiety and/or depression).History of self-harm practices and/or suicidal orhomicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual-current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant(gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse(oral, anal, vaginal, other),gender sexual preference, and any sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General:Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes:No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From headtotoe, includewhat you see, hear, and feel when conductingyour physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use "WNL" or "normal." You must describe what you see. Always document in head-to-toe format (i.e.,General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A.
Primay and Differential Diagnoses (list a minimum of 3differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
P.
Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor's treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Alsoinclude in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
References:
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7thedition formatting.