Soap note sample format for MRU
Name LP Date: 6/7/2019. Time: 1315
Age: 30 Sex: Female
“I am having vaginal itching and pain in my lower abdomen.”
HPI: Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for three weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She refuses any recent or historical known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She states normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx consists of the presence of DM and HTN.
Time with the patient: 40 minutes
Consult with preceptor: 20 minutes
Types of decision making: low-risk complications
Reason for hospital visit: “I am having vaginal itching and pain in my lower abdomen.”
Type of HP: an expanded problem focused
Social problems stated: sexuality, nutrition, disease screening, safety, immunization.
Procedural skills – direct observation.
ICD-10 Diagnosis Codes
Urinary tract infection, site not specified
Contraceptive management, not specified
STD-NOS,-latent Syphilis, unspecified
Trichomoniasis- trichomonas vulvovaginitis- trichomonas cystitis and urethritis
Candidiasis – candidiasis of vagina and vulva
Irregular menstruation, unspecified
New PT, OFFICE VISIT, 3 MAIN MODULES: PELVIC EXAMINATION AND HX; DECISION ON LOW-RISK COMPLICATIONS
URINALYSIS, DIP STICK/TABLET REAGENT; AUTOMATED W/MICROSCOPY
COLLECTION, VENOUS BLOOD
VITAL SIGNS DOCUMENTED AND REVIEWED
SELFCARE EDUCATION PROVIDED TO PATIENT
PRESCRIPTIONS CURRENTLY PRESCRIBED: #2
OTHER DETAILS ABOUT THE PATIENT
Smoking history: never
Colgan, R. & Williams, M. (2011). Diagnosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84(7), 771-776.
Heiner, B. & Gibson, M. (2011). Vaginitis: Diagnosis and Treatment. American Family Physician, 83(7), 807-815.
Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers (3rd Ed.). Philadelphia, PA: F.A. Davis Company.