Papsmear week 4

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Words 987 Date September 09,2020

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SOAP NOTE Name: WF Date:04/16/2019 Time: 1400 Age:27 Sex:F SUBJECTIVE CC: “I am here for my papsmear” HPI: Patient is a
27 year old WF that presents for annual gynecologic exam, denies any problems at this time, states she uses Nexplanon for
contraception and denies any problems with this contraception. Patient has no significant medical history. Last pap x 2 years
ago. Medications: Nexplanon Implant (Contraception) PMH Allergies: NKDA Medication Intolerances:NONE Chronic
Illnesses/Major traumas None Hospitalizations/Surgeries Tonsillectomy- age 17 Vaginal birth (twins) x 3 years ago Family
History Mother- Living with hypertension Father-Living with Hypertension Social History Lives with husband and twin
daughters. Denies substance use/abuse, ETOH, tobacco, and marijuana use. ROS General Denies weight change, fatigue,
fever, chills, night sweats, energy level changes Cardiovascular Denies chest pain, palpitations, PND, orthopnea, edema Skin
Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory Denies
cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB Eyes Wears contacts, blurring, visual changes of any kind
Gastrointestinal Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry
stools Ears Denies ear pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Denies urgency, frequency
burning, change in color of urine. In monogamous relationship withhusband for the past 5years. Denies history of STDS. Fe:
last pap x 2 years ago, does not performSBE. Denies menstrual complaints, vaginal discharge. Nose/Mouth/Throat Denies
sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Musculoskeletal Denies back
pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Breast Denies SBE, lumps, bumps or changes Neurological
Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Heme/Lymph/Endo Denies HIV status,
bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance
Psychiatric Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx OBJECTIVE Weight 180
BMI29.1 Temp98.9 BP130/86 Height 5’6 Pulse78 Resp18 General Appearance Healthy appearing adult female in no acute
distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. Skin Skin is
brown, warm, dry, clean and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic and without
lesions; hair evenly distributed. Eyes:PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral
TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal
deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa
pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with
regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No
edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal Abdomen overweight; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum
was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink andmultiparous. Scant clear to cloudy
drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended

bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. Rectal as
appropriate: no evidence of hemorrhoids, fissures, bleeding or masse, sphincter tone is firm Specimen collected and sent to
lab for examination. Patient tolerated procedure well. Musculoskeletal Full ROM seen in all 4 extremities as patient moved
about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and
oriented. Dressed in clean pants and shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and

oriented. Dressed in clean pants and shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and
cadence; answers questions appropriately. Lab Tests Wet prep – pending Pap Smear- Pending Special Tests N/A Diagnosis
Differential Diagnoses and Rationale o 1- Screening for malignant neoplasm of cervix Z12.4: Encounter for screening for
malignant neoplasm of cervix Rationale: Patients that fall within this patient’s age range should have a pap smear to screen
for cervical cancer every 5 years if most recent pap was noted to be normal (Schuiling&Likis, 2016). Diagnosis o 1- Screening
for malignant neoplasm of cervix Z12.4: Encounter for screening for malignant neoplasm of cervix Rationale: Patients that fall
within this patient’s age range should have a pap smear to screen for cervical cancer every 5 years if most recent pap was
noted to be normal (Schuiling&Likis, 2016). Reference Schuiling, K. D. &Likis, F. E. (2016). Women’s Gynecologic Health (3rd ed.).
Sudbury, MA: Jones & Bartlett. Retrieved from:
https://digitalbookshelf.southuniversity.edu/#/books/9781284124637/cfi/6/64!/4/2/6/26/12/6/[email protected]:0 Plan/Therapeutics o Plan:
� Further testing: No further testing currently. The need for further testing will be evaluated once the patient’s laboratory
results are in. � Medication No medications at this time. � Education Patient educated on performing SBE at home. Instructed
that she will be called to go over lab results. Non-medication treatments Instructed to return to the office in one year for
annual exam, or sooner, if needed. Evaluation of patient encounter ( PLEASE COMPLETE) The patient presented for a routine
medical examination. The patient’s most recent exam was noted to be WNL.I feel as though this exam went well. With the
preceptor’s guidance it was decided that the patient’s contraception should be continued as she has been on this
contraception without any problems. Patient Details Name: WF Age: 27 years Next of Kin: Husband Date: 16/20/19 Medical
History The patient has no known drug allergies that would interfere with the contraception causing any side effects. No
reported medical intolerances Has history of hypertension No current medications Significant surgical history of
Tonsillectomy at the age of 17 years Weigh 180, BMI 29.1, lesser than 30 Social History No reported drug abuse

Sources Similarity

Denies delayed healing rashes bruising bleeding or skin…

breast does sbe and denies lumps, bumps or changes neurological denies syncope, seizures, transient
paralysis, weakness, paresthesias, black out spells heme/lymph/endo denies hiv, bruising, blood transfusion
hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat…

https://www.coursehero.com/file/p4ol6ov/Denies-delayed-healing-rashes-bruising-bleeding-or-skin-
discolorations-any/

10%

Denies abdominal pain NVD constipation hepatitis hemorrhoids…

…abdominal pain, n/v/d, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools ears
denies ear pain, hearing loss, ringing in ears, discharge genitourinary/gynecological denies urgency,
frequency burning, change in color of urine. he is sexually activity, denies…

https://www.coursehero.com/file/p6ai6vt/Denies-abdominal-pain-NVD-constipation-hepatitis-
hemorrhoids-eating-disorders/

10%

Denies urgency frequency burning change in color of urine Patient…

patient uses the nuvaring for contraception, she is sexually activity, denies stds. she had her last pap,1 year
ago.denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx. she reports a
history of add since childhood.

https://www.coursehero.com/file/pir6c8/Denies-urgency-frequency-burning-change-in-color-of-urine-
Patient-uses-the/

10%

NoseMouthThroat Denies sinus problems dysphagia nose bleeds…

…dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain musculoskeletal denies back
pain, joint swelling, stiffness or pain, fracture hx, osteoporosis breast denies sbe, lumps, bumps or changes
neurological denies syncope, seizures, transient paralysis, weakness…

https://www.coursehero.com/file/p7v09j63/NoseMouthThroat-Denies-sinus-problems-dysphagia-nose-
bleeds-or-discharge-dental/

10%

Musculoskeletal Denies back pain joint swelling stiffness or pain…

breast denies sbe, lumps, bumps or changes. last mammogram 2018, normal. neurological denies syncope,
seizures, transient paralysis, weakness, paresthesia, black out spells heme/lymph/endo denies bruising,
blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger…

https://www.coursehero.com/file/p1i0f15/Musculoskeletal-Denies-back-pain-joint-swelling-stiffness-or-
pain-fracture-hx/

10%

Denies HIV status bruising blood transfusion hx night sweats…

Denies HIV status bruising blood transfusion hx night sweats…

denies depression, sleeping difficulties, suicidal ideation/attempts, previous dx objective weight 140.3 bmi
25.7 temp 98.6 bp 110/89 height 5’2” pulse 90 resp 18 general appearance healthy appearing adult female in
no acute distress. alert and oriented; answers questions appropriately.

https://www.coursehero.com/file/p67acf3/Denies-HIV-status-bruising-blood-transfusion-hx-night-sweats-
swollen-glands/

5%

HEENT Head is normocephalic atraumatic and without lesions hair…

heent head normal size and shape with no lesions or evidence of previous trauma. south university,
savannah.other related materials. 8 pages. heent head normocephalic with no evidence of lesions hair is
evenly distributed.

https://www.coursehero.com/file/p4a292h4/

5%

Bilateral TMs pearly grey with positive light reflex landmarks easily

bilateral tms pearly grey with positive light reflex; landmarks easily visualized. nose: nasal mucosa pink;
normal turbinates. no septal deviation.

https://www.coursehero.com/file/p7dipjv/Bilateral-TMs-pearly-grey-with-positive-light-reflex-landmarks-
easily/

5%

Respirations regular and easy lungs clear to auscultation bilaterally

neurological speech clear. good tone. posture erect. balance stable; gait normal. psychiatric alert and
oriented. dressed in clean jeans and shirt. maintains eye contact. speech is soft, though clear and of normal
rate and cadence; answers questions appropriately. no indication of depression noted.

https://www.coursehero.com/file/p4rnqhu5/Respirations-regular-and-easy-lungs-clear-to-auscultation-
bilaterally/

5%

SOAP_Blank_Template – Read online for free.

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the
skin.Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation.

5%

SOLUTION: endometrial cancers, health and medicine… – Studypool

genitourinary bladder is non-distended; no cva tenderness. external genitalia reveals coarse pubic hair in
normal distribution; skin color is consistent with general pigmentation.general appearance. the client is alert
and oriented. she answers questions promptly and appears neat.

https://www.studypool.com/discuss/4299451/endometrial-cancers-health-and-medicine-homework-help

5%

SOLUTION: Health and History assessment – Studypool

A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and
nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.

https://www.studypool.com/discuss/3291552/health-and-history-assessment

10%

Musculoskeletal Full ROM seen in all 4 extremities as patient…

patient instructed to follow up on the onset of her period education: the patient was counsel on wearing her
seatbelt, safe sex, texting and driving, underage drinking, sbe, hpv vaccine non-medication treatments: none
evaluation of patient encounter the nurse practitioner student was able…

https://www.coursehero.com/file/p4vj1n4/Musculoskeletal-Full-ROM-seen-in-all-4-extremities-as-patient-
moved-about-the/

4%

SOLUTION: SOAP note Endocrine, health and medicine… – Studypool

alert and oriented; answers questions appropriately.speech is soft, though clear and of normal rate and
cadence; answers questions appropriately. lab tests urinalysis—pending urine culture—pending wet prep—
pending special tests diagnosis include at least three differential…

4%

https://www.studypool.com/discuss/3893732/SOAP-note-Endocrine-health-and-medicine-homework-help

Encounter for screening for malignant neoplasm of cervix

Encounter for other screening for malignant neoplasm of breast Z12.39.

https://10icd.com/z00-z99/z00-z13/z12/code-z12-4.html

7%

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, fracture

hx, osteoporosis

Breast

SBE, lumps, bumps or changes

Neurological

Syncope, seizures, transient paralysis, weakness,

paresthesias, black out spells
Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night

sweats, swollen glands, increase thirst, increase

hunger, cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal

ideation/attempts, previous dx

3

OBJECTIVE – (if you are seeing a patient for an Episodic OV – PE should relate to the CC)
Weight BMI Temp BP
Height Pulse Resp
General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.

Slightly somber affect at first, then brighter later.
Skin

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs

intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive

light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.

Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.

Pulses 3+ throughout. No edema.
Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal

distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.

A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink

and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.

Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.

No adnexal masses or tenderness. Ovaries are non-palpable.

(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses).
Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait without abnormalities noted.
Psychiatric

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though

clear and of normal rate and cadence; answers questions appropriately.

4

Lab Tests (list the results if you have them)

Urinalysis – pending

Urine culture – pending

Wet prep – pending

Special Tests (done or ordered during the OV)

Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used

Primary Diagnosis (PER THE RUBRIC – YOU MUST PROVIDE SUPPORTING S&O

FROM THE CASE)

o

Differential Diagnoses (these must be different from the Primary Diagnosis) MUST BE

RELATED TO WHAT WAS OBSERVED/PE – DO NOT GO HUNTING FOR

ZEBRAS!!

o 1-
o 2-
o 3-

Plan/Therapeutics (explain fully) WRITE WHAT ED YOU PROVIDE TO THE PT – BE

SPECIFIC!! I NEED TO KNOW YOU KNOW WHAT YOU ARE TALKING ABOUT IN REGARD

TO THE ED PROVIDED!!!

o Plan:
▪ Further testing
▪ Medication
▪ Education
▪ Non-medication treatments

Evaluation of patient encounter – WHAT DID YOU LEARN FROM THE ENCOUTNER – BE

SPECIFIC HERE. NOT GENERIC INFORMATION!!

SU_NSG6430_W4_A2_Pandey_
R.doc.docx

by Ram Pandey

Submission date: 10-Sep-2020 08:50PM (UTC-0400)
Submission ID: 1384121034
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