HPI

  • Change “strange symptoms” and use the term that the patient used in stating her problem. Note the amount and consistency of the blood and if how many times she changed pantyliners in one day, if its soaked or not. 
  • 1/10 is a pain scale, if there is no pain do not use the scale and instead state that she don’t feel any pain
  • I got confused if weight loss is related to her symptoms or diet
  • HPI means history of present illness, previous illnesses should be on the past health history
  • Change the statement for the negative papsmear result to “but the patient claimed that she has positive result.”

OLDCART” which stands for Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors/Radiation and Treatment 

  • Character- should describe the blood/spotting
  • Aggravating factors- for ex.if the bleeding happens after sexual intercourse, during activity etc
  • Relieving factors- does not stop with any remedy

Medications -state how long she is taking the drug and if she’s compliant with her prescriptions

Hospitalizations-rearrange it according to dates, first is when she was 8

Family history-state cause of death of the parents and you stated the age of her siblings twice

Social history 

  • occupation is kinda confusing, state the job that she retired on. 
  • how many times is a frequent visit? 2-3x a week?once? Pls indicate 

ROS

General- is wt loss sudden?

PhysicalExam

General- Appears alert? 

Skin – pls describe the color of skin not the race, is the skin cold?warm to touch?

HEENT- describe the color of sclera

GI-what do you mean by the abdomen is obese? Pls describe using appropriate medical terms

Breast-I’m sorry i did not understand what you meant by  breast is selling and palpable axillary lymph?

Musculoskeletal- i think you no longer need to state that you observed the rom on waiting area?

Neuro – are you not required to take the reflexes such as tendon reflex, etc? 

Running head: SOAP 2


Soap notes

Name Ram Pandey

Professor: Dr.Regina Germonprez

Class: NSG 6430

Date of submission September 25, 2020

SOAP NOTES

Name: AP Age: 52 Sex: F Date: 11/09/2019 Time: 1700hrs

subjective

CC:

Breast cancer

AP, a 52-year-old woman, came to the hospital and complained of several signs. These included reddening of the nipple, breast discharge, which was not breast milk and had bloodstains, lump swell at the edge of the breast near the armpit, and general swelling and discomfort. She said that at first, the symptoms looked normal since it was only itching of the nipple, so she did not undergo any medication. She admitted that symptoms continued to worsen with pain in the chest, neck, and back pains which caused everyday fatigue, nausea, and lack of appetite. She had not undergone any lab tests and had only been under pain relievers.

Medication

Mammogram and ultrasound tests were conducted since her condition seemed to worsen to see any cancer cells. It was confirmed that the patient had breast cancer, and two procedures were conducted. These were chemotherapy and radiation therapy. In chemotherapy, drugs were inducted into the veins of the patient near the chest, which lasted an hour. The procedure was done to kill rapidly growing cells within the breast.

Radiation was done after lumpectomy, which was the removal of the swollen lump. This was done to prevent the risk of breast cancer recurrence in the affected breast.

Cysts

Tested negative

Fibroids

Tested negative

Another medical history

Never had any health complications related to breast cancer. From the record, the only case was flue infection, and the condition was treated without causing any threat to the health status of the patient.

Family history

Said mother had health complications and not alive. The father had no cancer complication although he passed own. In their family, there are two ladies and one man. All the ladies had breast cancer complications meaning that the disease had passed from the mother to the offspring through genetic transfer.

Social history

She is married to one partner, and they live together. He w

1

SOAP NOTE

Name: Date: Time:
Age: Sex:
SUBJECTIVE
CC:

Reason given by the patient for seeking medical care “in quotes”

HPI:

Describe the course of the patient’s illness, including when it began, character of symptoms, location

where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other

related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Medications: (list with reason for med )

PMH (include – immunization status including Gardisil, GTPLA)

Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries (include delivery of pregnancies here)

“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart

disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

Family History

Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:

lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Social History

2

Education level, occupational history, current living situation/partner/marital status, substance use/abuse,

ETOH, tobacco, marijuana. Safety status ADD VAPING

ROS (if you are seeing a patient for an Episodic OV – you may alter the ROS accordingly)
General

Weight change, fatigue, fever, chills, night sweats,

energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

Skin

Delayed healing, rashes, bruising, bleeding or skin

discolorations, any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia

hx, TB

Eyes

Corrective lenses, blurring, visual changes of any

kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis,

hemorrhoids, eating disorders, ulcers, black tarry

stools

Ears

Ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of

urine.

Contraception, sexual activity, STDS

Fe: last pap, breast, mammo, menstrual

complaints, vaginal discharge, pregnancy hx (This

should be in the in PMH as well.)

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or

discharge, dental disease, hoarseness, throat pain

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fractu

Clinical Note

Name:  Lisa

Date: 05/25/2019

Time: 1500

Insurance Type: (private)

Age: 60

Sex: Female

SUBJECTIVE

CC: 

“For three weeks, I have been bleeding irregularly.”

 

HPI: 

Mrs. Lisa, a 60-year old Caucasian GIT1R6, visits the Tn/Lyt clinic today complaining about irregular vaginal bleeds for 12 days. Lisa looks non-distressed and she claims to notice strange symptoms when bathing at her daughter’s house. At the age of 55 Lisa’s had her LMP therefore she was concerned. According to Lisa, the bleeding was “spotting” so she is now wearing one of the four panty lines per day. Mrs. Lisa states that the bleeding is sometimes brown and red in color at times. She has no idea of actions that can relieve her symptoms. Lisa rates her symptoms 1/10 as she reports no cramping or abdominal pains. The spotting is intermittent and the symptoms last few minutes or hours. Mrs. Lisa claims that the spotting develops all day and night and she has lose 80 pounds within the last two years. Lisa’s initial weight was 420 Ibs, and she now has 339 Ibs. Eliminating carbs and consuming more vegetables and lean meat in her diet is helping her lose her weight. Over the past 15 years, Lisa and her husband have not been sexually active. Mrs. Lisa’s last pap smear was in August 2017and she was negative. She claims to be diagnosed by an abnormal pap smear. Lisa has an HMO insurance plan and her last routine mammogram was in August 2017. She claims that before any procedures can be performed, diagnostic testing should be approved by insurance.

Patient’s HPI:

O- symptoms began three weeks ago

L- Vaginal bleeding.

D- The symptoms are intermittent.

C- Reports spotting in her pants.

A- The symptoms are not alleviated.

R- She does not report abdominal pains.

T- She experiences bleeding in the morning, day, and night.

T- So far, she hasn’t been treated.

S- Rates symptoms 1/10.

Naturally all women experience menopause when they reach 50 years old. This is the last stage of reproduction is a woman’s life where an amenorrhea follows 12 months after the females last menstrual cycle (Leaky, 2017). When a bleeding or spotting is detected after menopause it is considered abnormal. An encounter with a woman who experiences post-menopausal bleeding should entail treatment plan, physical examination, complete history and laboratory examination. The patient was given a complete physical exam, a comprehensive history taken, to eliminate anemia, and an endometrial biopsy a CBC was ordered to rule out endometrial cancer based on the medical recommendations.