Running head: WELL ADULT SOAP 1

KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT
ADULT, WOMEN, GERIATRICS

Student: Allison Rogers Course: NURS 5024

SOAP Note # 1- Well Adult

Pt. Initials: K.B. Age: 32 DOB: 11-11-84 LMP: 04-23-2017
(S) CC: Wishes to establish care, physical exam.

HPI:

Character: (Not applicable to this exam)

Onset: (Not applicable to this exam)

Location: (Not applicable to this exam)

Duration: (Not applicable to this exam)

Severity: (Not applicable to this exam)

Pattern: (Not applicable to this exam)

Associated: (Not applicable to this exam)

Medical Hx: G 1, T 1, P 0, A 0, L 1. Denies history of medical conditions

Surgical Hx: Denies past surgical history

Social Hx: Lives at home with husband and their 23 month-old daughter. Not currently
breastfeeding, reports breastfed for approximately six weeks postpartum until returning to work.
Currently working full time at local dental office as a dental hygienist, reports enjoys her job but
stays very busy at work. Reports good family support system. Goes to the gym after work (five
days per week) and reports taking a cardio class approximately 30 minutes each session. Denies
alcohol, tobacco, or illicit drug use.
Family Hx: Denies family history of hypertension, heart disease, diabetes, or cancer. Reports
mom and dad with obesity. Denies any additional medical, surgical, or social family history.

Meds/Allergies: No known drug, food, latex, or metal allergies. Currently taking Blisovi 24
Fe daily, and multivitamin daily.
ROS: General: Reports feeling rested, denies generalized weakness, recent fever, chills, or
unexplained weight loss or gain.
HEENT: Denies changes in vision or hearing, ringing in ears, nasal/ sinus problems, hoarseness,
or dry mouth.
WELL ADULT SOAP 2

Skin: Denies rashes, bruising, itching, dryness, discolorations, changes in moles, or changes in
hair.

Respiratory: Denies shortness of breath, cough, wheezing, or snoring.

Cardio: Denies chest pains/ angina, palpitations/ irregular heartbeat, edema/ swelling in
extremities, exertion with exercise or activity.
GI: Denies nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort, difficulty
swallowing or choking on foods/ drinks, painful swallowing, or rectal bleeding.
GU: Denies frequency of urination, painful urination, getting up at night to urinate, blood in
urine, dribbling, or incontinence of urine. Last papanicolaou (pap) test was approximately 2
years ago during pregnancy.
Diet: Denies change in diet or pattern of eating. Reports drinking mostly water and skim milk,
states she does have a coffee drink with cream/ sugar daily, denies soda. Most meals are home
cooked, baked instead of fried foods. Typical yogurt and fresh fruit for breakfast, sandwich for
lunch, and chicken or fish with vegetables and bread for supper. Reports typically no desserts or
snacks, on average snacking 2 times per week, popcorn or ice cream. Reports frustration with
current weight loss regimen.
Endocrine: Denies heat/ cold intolerance, excess sweating, excess urination, excess thirst, or
excess hunger.
MS: Denies muscle or joint weakness, stiffness, or pain. Denies limited range of motion, neck
or back pain.
Neuro: Denies headaches, dizziness, weakness, numbness, tingling, burning, tremor, or
seizures.
Psych: Denies feelings of anxiety, depression, suicidal / homicidal thoughts, or tendencies.

Other: States she is approximately 20 pounds heavier than her pre-pregnancy weight, and has
had difficulty getting the excess weight off since birth of her daughter 23 months ago.
(O)

Vital signs: T: 98.7F P: 85 R: 16 BP: 118/72 HT: 56 WT: 181 pounds (82kg) BMI:
29.2 Pain: Denies (0/10)
Constitutional: Pleasant, well-groomed, well-nourished Caucasian female. Dressed
appropriately for age and weather. Cooperative and answers questions appropriately. No
grimacing, guarding, fidgeting, or distress noted.
HEENT: Normocephallic. No infestations, flakes, abrasions, raised areas noted to scalp,
eyebrows, eyelashes, or facial area. Sclera white in color with no redness or irritations noted,
conjunctiva pink. Pupils equal, round, reactive to light, no nystagmus noted. Denies tenderness
WELL ADULT SOAP 3

of pinna or tragus bilaterally, tympanic membrane visualized, pearly gray bilaterally, no

drainage, bulging, or redness noted to membrane, or outer canal, small amount of yellow
cerumen noted bilateral. Nasal passageways clear, no redness, sores, deviated septum, polyps, or
nasal drainage noted. Lips pink and moist, no ulcerations or crustations noted. Oral cavity pink
and moist, no ulcerations, leukoplakia, dental caries, or abnormalities noted. Tongue midline,
able to move freely without difficulty, no glossitis, palate rises equally, uvula midline, tonsils
visualized 2+ bilaterally. Trachea midline, thyroid palpated, no goiter noted or tenderness
reported. Facial, neck, and supracervical lymph nodes non-palpable and non-tender.
Skin: Warm, dry, and intact, no lacerations, abrasions, ulcerations, ecchymosis, erythema, or
rashes.

Respiratory: Lungs clear all lobes bilaterally, no wheezing, crackles, or rhonchi noted. No
cough noted. Lung expansion equal and symmetrical bilaterally. AP diameter of chest 1:2, no
barrel chest noted. No clubbing of nailbeds.
Cardio: Regular rate rhythm, S1, S2 present, no rubs, gallops, murmurs noted. No edema noted
to upper/ lower extremities. No jugular vein distension, bruits, spider veins, or varicosities
noted.
GI: Normoactive bowel sounds noted in all four quadrants. Abdomen non-distended, soft, non-
tender.
GU: No bladder distension noted. Denies CVA tenderness bilaterally.

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

MS: No swelling or redness noted to joint areas bilaterally. Full range of motion noted to neck,
back, bilateral shoulders, arms, fingers, hips, knees, and ankles.
Neuro: Alert and oriented to person, place, time, and event. No tremors noted.

Psych: Appropriately interacts and answers questions, appropriate affect, no flat affect noted.
Does not appear anxious or in depressed mood, no fidgeting noted.
(A)
Dx: (include ICD 10 code - http://www.icd10data.com/ICD10CM/Codes )(list as many
diagnoses as indicated)

Z00.00 Encounter for routine general medical exam, E66.3 Overweight

Differentials:

1- (None available for this exam)

2- (None available for this exam)
3- (None available for this exam)
WELL ADULT SOAP 4

(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)
1. Thyroid Stimulating Hormone (TSH) - According to Fair Health Consumer (2016c), a TSH
laboratory test estimated out of pocket cost is $75 without insurance.
2. Thyroxine/ Assay of free Thyroxine (Free T4) - According to Fair Health Consumer (2016d),
a Free T4 laboratory test estimated out of pocket cost is $49 without insurance.
3. Urinalysis- According to Fair Health Consumer (2016e), a urinalysis laboratory test estimated
out of pocket cost is $9 without insurance.
4. Complete Blood Count (CBC) - According to Fair Heath Consumer (2016a), a CBC
laboratory test estimated out of pocket cost is $38 without insurance.
5. Complete Metabolic Panel (CMP) - According to Fair Health Consumer (2016b), a CMP
laboratory test estimated out of pocket cost is $58 without insurance.

Pt. Education: Discussed that pharmacotherapy options for weight loss are typically
recommended and reserved for patients with BMI of 27kg/m2 or higher with comorbidity or
BMI of 30 kg/m2 or higher (Grantham, 2017). Patients BMI is currently 29.2 kg/m2 with no
comorbidities, and she wishes to pursue a more natural option for weight loss, such as diet and
exercise, at this time. Liquid kilocalories, such as those found in sugar sweetened beverages for
example flavored coffee, do not have as strong satiety signaling properties as solid foods, which
can lead to greater kilocalorie ingestion throughout the day (Grantham, 2017). Therefore, it is
important to limit sugary drinks, such as the flavored coffee consumed daily, to special occasions
and instead drink plain black coffee or water. Reported diet regimen seems on track with food
preparation, encouraged to be conscious of portion sizes and calorie content. Grantham (2017)
state recommended aerobic exercise minimums are 30 minutes per day for moderate-intensity
exercises, which include brisk walking, bicycling and dancing. In order to prevent weight gain,
maintain weight loss, or weight loss, more than the minimum may be necessary (Grantham,
2017). Suggested to increase aerobic exercise and gym time to at least one hour per day. Taking
the extra time out for herself during daily will help to promote weight loss and increase
confidence and self-image.
Preventive care: Patient wishes to schedule pap test, states last was during pregnancy and
reports normal results. Pap test and clinical breast exam should be obtained every 3 years on
persons 21 or older (Kauschinger & Sandberg-Cook, 2017). Breast self-exam is controversial,
American Cancer Society recommends beginning at age 20, United States Preventative Services
Task Force recommends against teaching breast self-exam (Kauschinger & Sandberg-Cook,
2017). It is important to recognize the concept of breast self-awareness, and ensure the patient
understands breasts can undergo subtle changes throughout the menstrual cycle, but any
lingering changes or abnormalities that do not resolve should be reported, especially if unilateral.
Teaching the importance of knowing what is normal for you and your breast is essential in
detecting early changes.
Follow-up instructions: Scheduled for pap test and follow up in 6 months

Discuss how you addressed at least 3 NONPF competencies during this visit. (See
NONPF competency list available at 0 )
WELL ADULT SOAP 5

1- Scientific Foundation Competencies

According to Thomas et al. (2014), this competency is met through comparison of patient data
sets with evidence-based standards to improve care. I feel that I have met this competency by
evaluating and taking into consideration the patients vital signs, BMI, review of systems,
physical exam, medications, social, and family history in making an assessment and using
standards of care to compile a plan.

2- Technology and Information Literacy Competencies

This competency is met through the use of technology in clinical practice (Thomas et al., 2014).
By using electronic resources identifying current evidence-based practice in patient care this
competency has been met.

3- Independent Practice Competencies

An independent practice competency is met through health promotion, prevention, and
screenings (Thomas et al., 2014). This competency was met by reviewing social and family
histories and health promotion and prevention education. The importance of keeping scheduled
screenings, such as pap test and clinical breast exam, was also discussed with patient.
WELL ADULT SOAP 6

References

Fair Health Consumer [Internet] (2016a). Complete blood count. Retrieved from:

http://fairhealthconsumer.org/medical_cost.php

Fair Health Consumer [Internet] (2016b). Complete metabolic panel. Retrieved from:

http://fairhealthconsumer.org/medical_cost.php

Fair Health Consumer [Internet] (2016c). Thyroid stimulating hormone. Retrieved from:

https://fairhealthconsumer.org/medical_cost.php

Fair Health Consumer [Internet] (2016d). Thyroxine- Assay of free thyroxine. Retrieved from:

https://fairhealthconsumer.org/medical_cost.php

Fair Health Consumer [Internet] (2016e). Urinalysis. Retrieved from:

http://fairhealthconsumer.org/medical_cost.php

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

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

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

Kauschinger, E. D., & Sandberg-Cook, J. (2017). Routine 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.

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://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcor

ecompetenciesfinal2012.pdf