SOAP Note Template

Subjective

ID

First Name Elizabeth

Last Name Walker

Gender Female

Age 34

CC

Abdominal pain RLQ one hour with nausea. Reports pain is stabbing, sharp, strong, feels deep, rates pain 8 on scale 0-10.

HPI

History (including PMH, surgical, family, and social)

Elizabeth Walker is a 34-year-old married female who presents for evaluation of acute onset of RLQ abdominal pain with nausea for one hour. She characterizes the pain as sharp, constant, and worse with any movement. She reports associated nauseas, denies vomiting, fevers/chills, diarrhea, abnormal vaginal bleeding or discharge, lower urinary tract symptoms, or flank discomfort. PMH is notable for her currently undergoing hormonal stimulation fertility treatments (G0P0). The physician exam is significant for tachycardia, RLQ pain with guarding and rebound, as well as a tender right adnexal mass per pelvic examination. Other active problems: Infertility – takes HCG injections and FSH. Obstetric History: Gravida 0, Para 0, Abortus 0. Surgical History: 1. Tonsillectomy – @ age 14. Preventive: Flu immunization recommended yearly. BMI to 22.3 Seat belts – uses regularly. Texting while driving – never. Current on immunizations:1) up to date on Tdap. 2) up to date on influenza vaccination. Family History: Mother – 62 with HTN, alive and well. Father – 65 with diabetes, alive and well. Sister – 36 with two children, alive and well. Grandparents – deceased unknown causes. Social History: Tobacco – none. Alcohol – no. Recreational drugs – none. Married – monogamous. Education – college graduate. Job – elementary-school principal. Travel – none recently. Pets – none. Home safety – no guns in household.

ROS (general, skin, HEENT, neck, breasts, resp, CV, GI, peripheral vascular, urinary, genital/LMP, MSK, psych, neuro, hematologic, endocrine)

General: No evidence of fever, chills, fatigue, malaise, night sweats, excessive or unexplained weight gain or loss. Skin/Breasts: No rashes, bruising, jaundice, pruritis, acne, sores, ulcers, changes in moles, hair loss or brittleness, nails. No pain from her breasts. No lumps on bilat breasts. Does monthly self-breast exam. No discoloration near nipples or breasts. No nipple discharge. Periods are regular every 26-28 days. LMP three weeks ago. Uses three pads or tampons per day. HEENT/Neck: Denies vision changes, blurred vision; eye pain, discharge, itching, or redness. Denies ear pain, ear discharge, hearing difficulty, vertigo, nasal congestion, epistaxis, sinus pain or pressure, sore throat, swollen glands in neck, tooth pain. Cardiovascular: No complaints of chest pain/pressure, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, palpitations, ankle swelling. Resp: Denies shortness of breath, wheezing, cough/ sputum, hemoptysis, tightness in chest, pleuritic chest pain (pain with deep breath or cough). Abd/GI: C/o nausea and RLQ abdominal pain for last hour. No problems with appetite changes, dysphagia, vomiting, hematemesis, heartburn, diarrhea, constipation, melena. GU: No menstrual irregularities, amenorrhea, dysmenorrhea, dyspareunia.  Denies dysuria, urinary frequency, nocturia, hematuria, incontinence, urgency, hesitancy, difficulty starting or stopping stream. MSK: No joint or muscle pains, joint stiffness and swelling, limitations in movement, functionality. Neuro: No problems with headaches, syncope, presyncope, dizziness, weakness, paralysis, numbness/tingling, or balance. Allergic/Immunologic: Denies food allergies, hives, or rashes. Lymphatic/Endocrine: Denies polyuria, polydipsia, polyphagia, tremor, heat or cold intolerance, hot flashes. Hematologic: Denies excess bruising or bleeding, swollen glands/lymphadenopathy. Psychological: No problems with mood changes, feeling depressed, manic behaviors, auditory or visual hallucinations, anxiety, insomnia, suicidal or homicidal ideations.

Allergies

Penicillin. NKFA.

Current Medications

FSH and HCG injections.

Objective

Vital Signs:

BP 106/70 mmHg – sitting.

RR 14 unlabored

Pain 8

Height 5’ 4”

Weight 130 lbs. (59.1kg)

BMI 22.3

Temp 98.6 oral

Pulse Ox 99% room air

Physical exam (general, HEENT, neck/lymph, breasts, chest/respiratory, CV, GI/abdomen, GU/rectal, back, MSK, skin, neuro, psych)

Weight:  130.0 pounds. Skin/Breasts: Atraumatic, good skin turgor, skin, and scalp normal, no evidence of suspicious pigmented lesions. Normal symmetrical breast contour bilat. No overt inflammatory signs. No previous incisions or trauma. Left and right breast with no abnormalities. No axillary adenopathy. No expressible nipple discharge. HEENT: Eyes: Sclera and conjunctiva normal. Pupils and irises size symmetrical and shows normal reaction to light and accommodation bilaterally. Ears: no external scars or lesions. Otoscopic exam normal with only minimal wax, no masses or foreign bodies, good light reflex bilaterally. Nose: External without abnormality. Normal nasal mucosa, septum, turbinate’s. Mouth: Good dental hygiene. Neck supple, no adenopathy, trachea midline, no carotid bruits, thyroid size 25 gm, no masses or tenderness. Cardiovascular: No JVD. No thrills, heaves, or lifts. PMI normal size and location.  Heart RRR Normal S1 and S2, no murmurs appreciated. No carotid bruits, abdominal aorta normal size no bruits, pedal pulses present and symmetrical, no evidence of peripheral edema or varicosities. Respiratory: Normal chest shape, normal respiratory movement, no tenderness, and percussion normal. Auscultation found normal breath sounds throughout without wheezing, rales or ronchi. Abdomen/GI: Flat contour. No scars. Normal bowel sounds present. No hepatosplenomegaly. Severe tenderness to RLQ palpation below McBurney’s point, with associated guarding and rebound; no palpable mass. Mild tenderness to RUQ and LLQ palpations. No CVA tenderness. Liver edge felt below the coastal margin, span normal to percussion. Spleen normal size. GU/GYN: No lesions on external exam. Speculum exam: no blood or discharge present, cervix appears normal. Bimanual exam: right adnexal tenderness with palpable mass. No cervical motion tenderness. Normal genitalia, no evidence of infection. MSK: Normal ROM and muscle tone throughout. Muscle strength and flexibility throughout axial and appendicular skeleton normal. Motor 5/5 all extremities. Neurological: A & O x 4, good attention, memory, normal gait, CN 2-12 intact, reflexes 4/4 throughout. Normal cerebellar exam with finger to nose (FTN), rapid alternating movements (RAM), heal to shin (HTS) bilaterally. Allergic/Immunologic: No worrisome preauricular, posterior auricular, anterior cervical, posterior cervical, submandibular, supraclavicular lymph nodes. Lymphatic/Endocrine: Thyroid normal to palpation, 25 gm, no masses or tenderness. Hematologic: Normal capillary refill. No evidence of anemia.

Assessment

Problem List:

• Right Ovarian Torsion

Differential diagnoses:

Plan

Include the following:

• Medications to be prescribed (drug-dose directions)
• Instructions to continue, discontinue, or start medications, including changes to routine medications.
• Diagnostic tests in the proper order and reason for the order (e.g., CT abdomen and pelvis with and without contrast, Dx, LLQ abdominal pain)
• Labs, including appropriate serum panels (e.g., BMP, CBC with diff., TSH, T4, UA, C&S)
• Patient education pertinent to health condition
• Follow-up plan
• Referrals

Plan	Rationale and/or results
Pelvic Ultrasound	Results show an enlarged right ovary with no blood flow is diagnostic for ovarian torsion.  Right ovary 11cm x 4cm with small cyst. No blood flow to right ovary seen. Left ovary 4cm overall size. No pathology identified.
CBC	Name Value Units Reference Range White blood cells (WBCs) 11200 mm3 4,000-10,000 Red Blood Cell Count (RBC) 4.9 million/µl 4.5-5.9(), 4.0-5.2(), adults Hemoglobin (Hgb) 12.2 g/dl 14-18(), 12-16(), adults Hematocrit (Hct) 38.4 % 42-54(), 37-47(), adults Mean corpuscular volume (MCV) 91 fl 82-103, adults Mean corpuscular hemoglobin (MCH) 28 µm3 26-34, adults Mean corpuscular hemoglobin concentration (MCHC) 31 % 30-37, adults Platelets (thrombocytes) 280 k/dL 150-399, adults Red cell distribution width (RDW) 12.0 % 11.5-14.5, adults Neutrophils 74 % 46-78, adult Lymphocytes 23 % 18-52, adult Monocytes 1 % 3-10, adult Eosinophils 1 % 0-6, adult Basophils 1 % 0-3, adult Segmented neutrophils 72 % 36-72, adult Band Cells 2 % 0-6, adult
hCG, urine	Name Value Units Reference Range Human chorionic gonadotropin (HCG), urine Negative None ( and non-pregnant ); detectable (pregnant )
UA	Name Value Units Reference Range Color Amber Interpreted by physician Clarity Clear clear Odor Normal slightly nutty pH 5.4 4.5-8 Protein 1 mg/dL 0-8 Specific gravity 1.019 1.002-1.030 Osmolarity > 400 mOsm/L >400 Leukocyte esterase Negative negative Nitrites Negative 0 Ketones Negative negative Bilirubin Negative negative Blood (heme) Negative negative Urobilinogen 0.5 EU/dL 0.2-1.0 Crystals None Interpreted by physician Casts 0-1 hyaline casts/lpf 0-4 Glucose, urine Negative negative White blood cells (WBCs) 0-1 hpf 0-5 Red blood cells (RBCs) 0-1 hpf 0-5 Red blood cell casts None none SQEP 0-1 lpf <5 Bacteria Negative negative on spun specimen Creatinine 8 5-19 Occult blood Negative negative
STAT GYN surgical referral for removal of right torsed ovary STAT.	Start IV access to provide for analgesia. Order blood work for chemistries and coagulation studies as part  Of the preoperative workup. Monitor vital signs. Patients’ tachycardia will most likely improve with Analgesia and pain control. Prep for emergent laparoscopy to detorse the ovary and thereby restore Dont wait until the last minute. Provide your requirements and let our native nursing writers deliver your assignments ASAP. Start My Order Perfusion.
Referral for education, counseling, supported decision making and support groups for infertility and loss of ovary.

Name	Value	Units	Reference Range
Human chorionic gonadotropin (HCG), urine	Negative		None ( and non-pregnant ); detectable (pregnant )