OBGYN SOAP Note example PDF

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obgyn soap note example during clinicals...

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Christine Patrissi Professor Bush

NUR639 SOAP #10

May 24th, 2019 S: T.L. is a 45 y/o Caucasian female who presents with perimenopausal symptoms including hot flashes, night sweats and anxiety. She reports that these symptoms have occurred over the last years and are worse particularly one week prior to menses. Menses is regular, occurring every 28 days, and is very light and short, requiring one pad/day and lasting 3-5 days s/p a hysteroscopic endometrial ablation in 2016. Denies vaginal dryness, dyspareunia, memory loss, insomnia, dysuria. Denies smoking or illicit drugs. Reports occasional alcohol use. No hx of abnormal PAPs or STDs. Denies any other PMH or any FHx of colon, uterine, breast, or ovarian cancers. Allergy to PCN. O: Constitutional: Appears obese and mildly anxious. No signs of apparent distress present. Alert and oriented. Vital Signs: BP 134/88, HR 76/min, RR 18, Temp 97.4, Wt. 268lbs., Ht. 67”, BMI 42. Skin: Warm, pink, and dry. No suspicious lesions or nevi. Neck: Supple and symmetric. No lymphadenopathy. Thyroid not palpable, no masses or lumps. Cardiovascular: Heart RRR, normal S1 and S2. No rubs, murmurs, or gallops. Respiratory: Lungs CTAB. Respirations easy, non-labored. Abdomen: Protuberant, soft, nontender and nondistended without guarding, rigidity or rebound tenderness. No palpable hepatosplenomegaly. Extremities: Peripheral circulation is normal with no evidence of clubbing and cyanosis. No edema bilaterally. No varicosities noted. Breasts: Symmetric in shape and size. No dimpling of the breasts bilaterally. No lesions or puckering of the breasts. No dominant masses noted. No discharge, inversion or lesion of the nipples bilaterally. Axillae: No lymphadenopathy or mass of the axillae, infra/supraclavicular bilaterally. Pelvic Exam: External genitalia- hair distribution of normal female pattern. No vulvar erythema or lesions. Vagina: walls pink, moist, rugae present, well estrogenized w/o lesions. No prolapses noted. Cervix: Without lesions, discharge or bleeding. No polyps. Bimanual: Suboptimal due to body habitus. Neg CMT. Uterus midline, mobile, soft and nontender. No adnexal tenderness or masses. A: Perimenopausal Vasomotor Symptoms

P: Pharmacologic: Venlafaxine Hydrochloride (Effexor) – 37.5mg ER 1 tab PO Daily. If symptoms do not resolve or worsen, can also consider options such as hormone replacement therapy (with progesterone included since she has an intact uterus), Gabapentin, Clonidine, Vistaril. Nonpharmacologic: Avoid personal triggers (hot drinks, caffeine, spicy foods, alcohol, emotional situations), exercise/yoga, acupuncture, and herbals (soy, black cohosh). Encourage weight loss....