Soap Note United States University FNP 592 Common Illnesses

Soap Noteunited States Universityfnp 592 Common Illnesses Across The

Provide a comprehensive SOAP note for a female patient, 58 years old, presenting for a routine gynecological examination. The note should include subjective data (history of present illness, past medical history, social history, immunizations, spiritual background, mental health status, review of systems), objective findings (vital signs, physical examination across all systems), assessment with final diagnoses, and an outlined plan including diagnostics, treatments, patient education, follow-up, and referrals. Summarize findings consistent with a healthy routine exam, and include necessary screening and preventive care recommendations for her age group.

Paper For Above instruction

The following case outlines a comprehensive approach to a routine annual women’s health examination in a primary care setting, emphasizing preventive screening, physical assessment, and patient education grounded in evidence-based guidelines. The pattern of care exemplifies thoroughness in history-taking, detailed physical exam, and appropriate screening strategies for a woman aged 58, aligning with age-specific recommendations to promote health and early detection of potential illnesses.

Introduction

Routine health maintenance for women, especially in later adulthood, plays a critical role in disease prevention and health promotion. This case involves a 58-year-old Hispanic female presenting for her annual gynecologic exam, with no current complaints or abnormal findings. Conducting a comprehensive assessment includes gathering subjective data, performing a meticulous physical examination, and establishing an appropriate scope of diagnostic screenings. This process aligns with guidelines from authoritative sources such as the U.S. Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG).

Subjective Data Collection

Chief Complaint and History of Present Illness

The patient reports no current complaints, experiencing no changes in her health status, recent illnesses, or new symptoms. Her main reason for visit is a routine annual examination. She denies any fever, shortness of breath, dizziness, or headache. She states she feels well and has no specific concerns at this time.

Past Medical and Surgical History

Her medical history is unremarkable, with no recent hospitalizations or surgeries. She reports no chronic illnesses such as hypertension, diabetes, or thyroid problems. Her previous health screenings, including eye and hearing, were normal as of recent exams. She reports lactose allergy but no other medication allergies.

Medications and Allergies

The patient is not on any chronic medications. She reports an allergy to lactose but denies drug allergies or sensitivities.

Family History

• Mother: Deceased at 73 due to myocardial infarction (MI), with a history of hypertension (HTN).
• Father: Deceased at 77 from stroke, with a history of HTN.
• Maternal grandmother: Deceased at 76 from a car accident, no known health issues.
• Paternal grandparents: Unknown health history.

Social History

• Reproductive: Heterosexual, four living children, denies current sexual activity or use of contraception.
• Tobacco/Vaping: Never smoked.
• Alcohol: Consumes approximately one drink per week socially.
• Drug use: Denies recreational drug use.
• Marital Status: Single.
• Occupation: Waitress at a local restaurant.
• Diet and Exercise: Primarily Mexican food, walks daily around the block for exercise.
• Sleep/Stress: Reports 6-7 hours of sleep; no significant stressors.
• Housing: Lives with her oldest daughter in a nonsmoking home, no pets, with three grandchildren.
• Safety & Safety Behaviors: Uses seatbelt, denies risky behaviors, no guns at home.

Immunizations and Preventive Care

Up to date on childhood immunizations. Recent vaccines include the COVID Johnson & Johnson shot (3/23/2021) and Pfizer booster (2/1/2022). Last flu vaccine was 2/1/2022. She received Tdap in 2019. She is aware of importance of routine screenings.

Spirituality and Mental Health

Identifies as Catholic and attends church regularly. Denies depression, anxiety, SI/SA, and reports satisfaction with her life.

Review of Systems (ROS)

States no current constitutional symptoms such as fatigue or weight changes. Denies symptoms across all other bodily systems, including eyes, ears, nose, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, skin, and peripheral vascular.

Objective Data and Physical Examination

Vital Signs

• Pulse: 75 bpm
• Blood Pressure: 122/78 mm Hg
• Respiratory Rate: 18/min
• Temperature: 97°F orally
• SpO2: 97% on room air
• Height: 5'4"
• Weight: 161 lbs
• BMI: 25.99

Physical Examination Findings

General Survey

Patient appears well-nourished, appropriately groomed, alert-and-oriented x4. Engages effectively during the exam, maintaining eye contact. No signs of distress.

HEENT

Normocephalic, atraumatic. Ears: TMs clear, no bulging or erythema. Nose: Midline, no drainage. Mouth: Moist mucosa, no lesions, erythema, or sores. Throat: No edema or exudate. Eyes: Sclera white, EOM intact, no photophobia or discharge.

Neck

Supple, no lymphadenopathy or thyroid enlargement. Trachea midline, full ROM.

Chest and Breasts

Symmetrical, no deformities, no tenderness. Breath sounds clear, no adventitious sounds.

Cardiovascular

Regular rhythm, S1 and S2 normal, no murmurs or extra sounds.

Abdomen

Soft, non-tender, no distention or masses. Normal bowel sounds.

Genitourinary

Normal external genitalia, no lesions, discharge, or tenderness. Uterus: Non-enlarged, midline. Adnexa: No tenderness.

Lymphatic & Extremities

No peripheral lymphadenopathy. Pulses intact +2 bilaterally. No cyanosis or clubbing.

Musculoskeletal & Neurologic

Full ROM, 5/5 strength. Gait steady, no deficits. Cranial nerves grossly intact. Mood and affect appropriate, no neurological deficits.

Skin

Normal for ethnicity, no lesions or rashes.

Assessment

1. Routine annual women’s health exam with normal findings (ICD Z01.00)
2. Screen for cervical abnormalities (Pap smear)
3. Preventive screenings based on age

Plan

Diagnostics

• Order Pap smear (Thin Prep) for cervical cancer screening.
• No additional lab tests unless indicated by findings.

Treatment and Preventive Care

• Continue current medications if any
• Discuss HPV vaccination if she is eligible
• Recommend mammogram screening per age guidelines
• Advise on lifestyle modifications such as healthy diet and physical activity

Patient Education & Follow-up

• Advise that mild cramping may occur post-Pap, relieved by OTC ibuprofen.
• Notify immediately if experiencing irregular bleeding, heavy bleeding, or severe pelvic pain.
• Results will be communicated via phone; schedule follow-up accordingly.
• Encourage scheduling a mammogram and routine screenings every 1-3 years.

Referrals

• Refer to OB/GYN if abnormal findings on Pap smear or if further evaluation is needed, such as colposcopy or biopsy.

This comprehensive approach ensures age-appropriate preventive care, early detection of gynecological malignancies, and promotes ongoing health maintenance, consistent with current clinical guidelines and best practices.

References

• American College of Obstetricians and Gynecologists. (2019). Practice Bulletin No. 168: Cervical Cancer Screening. Obstetrics & Gynecology, 133(2), e92–e105.
• U.S. Preventive Services Task Force. (2021). Recommendations for Cervical Cancer Screening. USPSTF.
• Mayo Clinic. (2019). When to start mammograms. Retrieved from https://www.mayoclinic.org
• National Cancer Institute. (2019). HPV and Pap testing. Cancer.gov.
• Centers for Disease Control and Prevention. (2022). Breast Cancer Screening Guidelines. CDC.
• American Cancer Society. (2020). Cervical Cancer Prevention and Early Detection. ACS.
• Hoffman, D. J., & Burt, R. K. (2020). Gynecologic Cancer Screening. In Williams Gynecology (3rd ed.). McGraw-Hill Education.
• Reed, B. D., et al. (2020). HPV Vaccination and Screening. Journal of Women's Health.
• CDC. (2022). Breast Cancer Screening Recommendations. Centers for Disease Control and Prevention.
• ACOG Committee Opinion. (2018). Screening for Cervical Cancer. Obstetrics & Gynecology, 131(6), e179–e186.