Can anyone help me to write soap note for the following case? Thanks!

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tuf06150

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CC : “I want to start birth control.”


HPI: M is a 36 year-old Caucasian female who presents to clinic to inquire about contraception. She has been in a monogamous relationship with her boyfriend for the past 1.5 years. She finds condoms to be cumbersome and a couple of weeks ago the condom broke. She has 2 children and her boyfriend has 3- she does not want any more children. Life is hectic right now as both her children are involved in several after school activities and they are in the process of moving into her boyfriend’s house.


PMH: Allergic rhinitis, asthma, migraine headache (with aura), acne


FH: Mother and father A&W; brother passed away at age 19 in a motor vehicle accident


SH: divorced; 2 children (ages 8 & 10); real estate agent; (+) tobacco (5 cigarettes/day), (-) illicit drugs; (+) alcohol (2-3 glasses of wine/week)


ALL: NKDA


Medications: Advair 250/50, inhale 1 puff PO BID (asthma)

Differin 0.1% gel, apply to affected area once daily at bedtime for acne

Loratadine 10 mg PO daily PRN seasonal allergies

Proair HFA, inhale 1-2 puffs PO Q4-6H PRN SOB (asthma)

Sumatriptan 25 mg PO at the first sign of migraine; may take a second dose 2 hours later if no relief


ROS: Denies headache, fatigue, SOB, chest pain, abdominal pain, N/V/D, dysuria, vaginal discharge; swelling, pain, or edema in the extremities; (+) numerous comedones on face


Physical exam:

VS: BP 110/70 mmHg, HR 76 bpm, RR 17 bpm, T 98.6°F, Wt 182 lb, Ht: 5’5”

Skin: ~12 open comedones on nose, 8 closed comedones on chin, 2 closed comedones on forehead; no evidence of scarring; skin is non-oily

HEENT: No carotid bruits; PERRLA; EOMI; (-) hemorrhages, exudates or AV nicking

Neck: (-) JVD

CV: RRR; normal S1 and S2; no S3, S4, murmurs, rubs, or bruits

Lungs: CTA

Abd: Soft, NTND, central obesity, normal BS

GU: Normal vaginal exam without tenderness or masses

Ext: (+) distal pulses

Neuro: A&O x 3; CN II-XII intact


Labs (fasting):

Na 140 mEq/L Hgb 13.0 g/dL T. cholesterol 170 mg/dL

K 3.7 mEq/L Hct 38% TG 90 mg/dL

Cl 100 mEq/L Plt 300 x 103/mm3 HDL 45 mg/dL

CO2 25 mEq/L WBC 7.0 x 103/mm3 LDL 107 mg/dL

BUN 12 mg/dL

SCr 1.0 mg/dL ALT 24 IU/L

Glucose 115 mg/dL AST 26 IU/L

A1c 5.8%

eGFR 63 mL/min/1.73m2

Two Months Later



Two months later, M is admitted to the hospital with an asthma exacerbation. While in the hospital, she is treated with methylprednisolone 40 mg IV daily.



Three Years Later


Three years later, M, a 39 year-old Caucasian female, presents to the clinic complaining of feeling tired and cold all the time. She has no energy- she has really been struggling and doesn’t know if there is anything she can do. Her provider sends her for labs.


Physical Exam

Gen: Well-appearing, NAD

VS: BP 118/74; HR 70; RR 18 bpm, T 36.4 C Ht 5’5”, Wt 185 lbs

Skin: Dry appearing skin and scalp; (-) rashes or lesions

HEENT: PERRL, EOMI

Neck: (-) thyroid nodules or goiter; (-) lymphadenopathy

Lungs: CTA bilaterally

Heart: RRR, normal S1, S2; (-) S3 or S4

Abd: Soft, NTND

GU/Rect: deferred

Ext: 2+ DP pulses bilaterally

Neuro: A&Ox3; CN II-XII intact; DTRs 2+, symmetric


Labs (fasting):

Sodium 138 mEq/L TSH 15.8 mIU/L

Potassium 4.3 mEq/L Free T4 0.1 mcg/dL

Chloride 98 mEq/L

Bicarbonate 25 mEq/L

BUN 9 mg/L

SCr 0.9 mg/L

Glucose 110 mg/L


Thirty Years Later



PMH: HTN x 7 years, type 2 DM x 5 years, allergic rhinitis, asthma, migraine headache (with aura)


FH: Mother ¯ 78 – colon cancer, father ¯ 82 – complications of diabetes; 2 adult children & 3 adult step-children A&W


SH: Married; real estate agent; (+) tobacco (5 cigarettes/day), (-) illicit drugs; (+) alcohol (1-2 glasses of wine/week)


Meds: Pt reports adherence to the following medications:

Advair 500/50, inhale 1 puff PO BID (asthma)

Amlodipine 10 mg PO daily (HTN)

Aspirin 81 mg PO daily

Atorvastatin 40 mg PO daily (lipids)

Levothyroxine 125 mcg PO daily

Loratadine 10mg PO daily PRN seasonal allergies

Metformin 1000 mg PO BID

Pioglitazone 30 mg PO daily

Proair HFA, inhale 1-2 puffs PO Q4-6H PRN SOB (asthma)

Sumatriptan 25 mg PO at the first sign of migraine; may take a second dose 2 hours later if no relief


ALL: NKDA


Immunizations: Influenza vaccine (10/2002)


ROS: Denies fatigue, polyuria, polydipsia, blurry vision, chest pain, dizziness, shortness of breath.


Physical Exam:

VS: BP 136/84 mmHg, HR 76 bpm, RR 17 bpm, T 98.6°F, Wt 230 lb, Ht: 5’5”

HEENT: No carotid bruits; PERRLA; EOMI; (-) hemorrhages, exudates or AV nicking
Neck: (-) JVD

CV: RRR; normal S1 and S2; no S3, S4, murmurs, rubs, or bruits

Lungs: CTA

Abd: Soft, NTND, central obesity, normal BS

GU: Deferred

Ext: (+) distal pulses, +1 pitting edema

Neuro: A&O x 3; CN II-XII intact


Labs (fasting):

Na 141 mEq/L Total cholesterol 178 mg/dL Vitamin D 22 ng/mL

K 4.0 mEq/L TG 165 mg/dL

Cl 102 mEq/L HDL 42 mg/dL

CO2 24 mEq/L

BUN 19 mg/dL AST 26 IU/L

SCr 1.1 mg/dL ALT 24 IU/L

Glucose 120 mg/dL


A1c 7.3% eGFR 49 mL/min/1.73m2


UA: (-) ketones, (-) protein, (-) glucose

Albumin:creatinine 22 mcg/mg


M was sent to get screened for osteoporosis. She returns a month later to discuss her results.


DXA of lumbar spine (L2-4): T-score:-1.6 SD; Z-score:-0.5 SD

DXA of right femoral neck: T-score:-2.2 SD; Z-score:-0.4 SD

DXA of left femoral neck: T-score -1.9 SD; Z-score: -0.4SD

X-Ray Spine: no fractures noted


FRAX: Major osteoporotic 12%; hip fracture 3.7%
 
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CherryRedDracul

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SDN is not for homework help. You have a lot of the information already laid out for you. What you need to do is to take the salient points from her past appointments and incorporate them into your current SOAP note.
 
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BacktotheBasics

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SDN is not for homework help.
 

Bacchus

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Closed. Not for HW help. Although we assume the name is made up, it has been edited out.
 
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