Nursing SOAP Note Example
SOAP NOTE
Name: SH |
Date: 6/25/2020 |
Time: 11:AM ET |
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Age: 16 |
Sex: Female |
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SUBJECTIVE |
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CC: The chief complaint is that the patient has abnormal vaginal bleeding. While this is a normal occurrence in many teenagers, it could also the sign of multiple long term illnesses, which need gynecological and pediatric follow-up. Strenuous exercise, ovulation, and immaturity of the reproductive mechanisms could all cause bleeding in between menstrual cycles (Grey & Emmans, 2007). |
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HPI: The present symptoms presented around 3 days ago. The patient is not menstruating. The bleeding is minimal and sporadic – mainly spotting, with no pain or discomfort reported by the patient. By relaxing her workout schedule, as well as physical workload, the patient has seen a noticeable reaction in the bleeding. In the early hours of the night, the patient has noticed increased bleeding, but this dissipates as the night wears on. The patient rates the severity of the illness at 5, on a scale of 1-10. |
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Medications: The patient is not taking any medication at the moment. |
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PMH Allergies: None reported Medication Intolerances: None reported Chronic Illnesses/Major traumas- None reported Chronic Medical Problems: None reported Hospitalizations/Surgeries- None reported Immunizations all prescribe immunizations received Safety: Good Exercise and leisure Exercises daily – lifting light weights, and jogging for around 5 km daily. Sleep: Used to sleep well; this has however been disrupted by the bleeding. The patient needs to wake up regularly due to emotional stress and the need to change pads, even though the bleeding is minimal. |
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Family History: The patient lives with her parents and three younger siblings. The father is a blue collar worker, while the mother is a home maker. The patient actively assists in chores in the house, including caring for her 3 younger siblings. The parents have not underlying conditions that the patient is aware of, neither are her siblings. |
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Social History The patient lives in a safe neighborhood, with reasonable social amenities’ provision. The patient is currently an 11th grader in a local school, where she is active in sports. Her diet is healthy, with only occasional fast food treats. She has no drug use history or symptoms. She is not sexually active, or exhibiting any stress or depression signs. The family is reasonably financially stable, and the patient expects to join college once she is done with high school. |
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ROS |
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General Good |
Cardiovascular Good |
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Skin good |
Respiratory good |
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Eyes good |
Gastrointestinal good |
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Ears good |
Genitourinary/Gynecological Evidence of bleeding recorded |
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Nose/Mouth/Throat Good |
Musculoskeletal good |
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Breast good |
Neurological good |
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Heme/Lymph/Endo Good |
Psychiatric: good |
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OBJECTIVE |
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Weight 51kg BMI 20 |
Temp 35.6 |
BP 110/70 mm hg |
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Height – 63 cm |
Pulse – 65 bpm |
Resp – good |
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General Appearance Very fit, and otherwise healthy. |
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Skin Healthy skin uses common deodorants and lotion. |
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HEENT Head: no headache or discomfort reported Eyes: good eye acuity Ears: good ear acuity, the eardrum and other parts of the ear otherwise healthy. No pain reported by the patient. Nose: Pharynx and uvula are normal, as are other areas of the nose. Mouth: no nodules, carcinoma, or ulcerations detected Neck: nodes are healthy – consistent, at the right place, and of the expected size. |
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Cardiovascular Heartbeat and pulse are normal, and patient does not report any pain or discomfort in the chest, or unexplained fatigue. |
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Respiratory: lungs are healthy and working properly |
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Gastrointestinal: no digestive issues reported, or intolerance to specific foods in and before the current condition. |
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Breast: no lump or inconsistent texture noted, or discomfort reported by the patient. |
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Genitourinary Slight blood discharge seen during examination. Other parts of the reproductive and urinary systems appear to be healthy. |
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Musculoskeletal: healthy, with no pain reported by patient, or abnormalities seen during physical examination. |
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Neurological Healthy |
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Psychiatric NO issues with stress or depression reported. Physical examination also reported no medical issues relevant with the symptoms presented. |
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Lab Tests: Prescribed laboratory examination suggested that the bleeding may be caused by issues with the hypothalamic-pituitary-ovarian systems, which are not yet mature. |
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Special Tests: None proffered. |
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Diagnosis |
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Differential Diagnoses:
Diagnosis The patient is diagnosed as having immature hypothalamic-pituitary-ovarian systems. In particular, premature ovarian failure has led to the bleeding, since the patient spears to be ovulating, or has just passed the ovulation process. This is known to cause such bleeding as exhibited by the patient. |
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Plan/Therapeutics |
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Evaluation of patient encounter- The patient is reasonable and knowledgeable. She has not panicked, though she is worried about what this could mean for her health. She has read online about the condition, which has heightened her anxiety Apart from this; she is doing well, and is highly appreciative of the thoroughness of the medical examination to establish the cause of her condition. The patient is expected to stick to the medication prescribed, going by her willingness to solve the issue, and her trust of the services offered by the medical personnel at the health facility. |
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References
Grey, S., Emmans, S. (2007). Abnormal Vaginal Bleeding in Adolescents. An Official Journal of the American Academy of Pediatrics, 28 (5), 175-182.
Podder V., Lew V., Ghassemzadeh S. (2020). SOAP Notes. Treasure Island, Florida: StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482263/