Miami Regional University Date of Encounter:06/18/2020 Student Name: LWC Preceptor: Silvio Planas APRN Clinical Site:Gynecology and More INC. Clinical Instructor:Kirenia Santiuste Soap Note # 6 Main Diagnosis:Allergic Rhinitis PATIENT INFORMATION · Name: TJ · Age: 28 · Gender at Birth: Female · Gender Identity: Female · Source: Patient · Allergies: allergies to dust, cats and Penicillin · Current Medications: Albuterol 90mcg, 1-2 puff qid inhaler PRN when symptoms occur. · PMH: Asthma · Immunizations: Up to Date, Refused Influenza vaccination this year due to COVID-19 National Pandemic · Preventive Care: Avoid allergens, Good house hygiene, Regular exercising, annual checkups. · Surgical History: Appendicitis. · Family History: 1st relatives Asthma, Mother and grandparents High blood pressure, Father died on car accident DM. · Social History: Alcohol drinker 2 cups or rum weekly. Preferred hobby Netflix and sport tv programs. · Sexual Orientation: Female Preference · Nutrition History: Low Sodium Diet Subjective Data: · Chief Complaint: “I have sore throat and itchy, itchy eyes and runny nose” · Symptom analysis/HPI: Patient has been with those symptoms for a week, the runny nose and eye itchy are the same but the sore throat got worse lately, the discharge is clear. There is tenderness around the nose. The Symptoms improve drinking water and some drops throat lozenges. Denies fever, no nasal blockage, no chills. Review of Systems (ROS) · General: Fatigued, Generalized Weakness. · HEENT: Runny nose, eyes itchy, sore throat, difficult swallowing, blurred vision when reading, no double vision., denies block nose and no bleeding. · Neck: Denies neck pain, able to rotate his neck laterally and in and upward position · Lungs: No cough, shortness of breath, PND, or orthopnea · Cardiovascular: No pressure, squeezing, tightness, heaviness or aching about the chest, neck, axilla or epigastrium · Breast: Denies any pain or lumps · GI: Denies Abdominal Pain · Female genital: Denies dysuria, frequency and urgency when urinating · GU: Denies dysuria, no frequency and urgency when urinating · Neuro: No burning or tingling, sensation present in all quadrants · Musculoskeletal: No joint pain no restriction motions. · Activity & Exercise: no habits of exercise. · Psychosocial: anxious about the disease. · Derm: denies any rash, bums or recent lesions. · Sleep/Rest: more than 6 hours a day but with difficult to breath. Objective Data/Physical Exam · BP 141/82 TPR 99.1 HT 170 cm WT. BMI 30.1 O2: 99% · General: Well-groomed, appropriate posture and gait, normal affect, obesity · HEENT: Tenderness frontal and right maxillary sinus, Weber and Rinne test intact, cranial nerves intact, no hearing loss, vision left eye 20/20 right eye 20/40. whitish discharge noted from the nose. Edema and erythema of nasal mucosa, uvula and Tonsils, redness noted. Halitosis presents. · Neck: thyroid gland intact no nodules no lym ...

1. Miami Regional University
Date of Encounter:06/18/2020
Student Name: LWC
Preceptor: Silvio Planas APRN
Clinical Site:Gynecology and More INC.
Clinical Instructor:Kirenia Santiuste
Soap Note # 6
Main Diagnosis:Allergic Rhinitis
PATIENT INFORMATION
· Name: TJ
· Age: 28
· Gender at Birth: Female
· Gender Identity: Female
· Source: Patient
· Allergies: allergies to dust, cats and Penicillin
· Current Medications: Albuterol 90mcg, 1-2 puff qid inhaler
PRN when symptoms occur.
· PMH: Asthma
· Immunizations: Up to Date, Refused Influenza vaccination this
year due to COVID-19 National Pandemic
· Preventive Care: Avoid allergens, Good house hygiene,
Regular exercising, annual checkups.
· Surgical History: Appendicitis.
· Family History: 1st relatives Asthma, Mother and
grandparents High blood pressure, Father died on car accident
DM.
· Social History: Alcohol drinker 2 cups or rum weekly.
Preferred hobby Netflix and sport tv programs.
· Sexual Orientation: Female Preference

2. · Nutrition History: Low Sodium Diet
Subjective Data:
· Chief Complaint: “I have sore throat and itchy, itchy eyes and
runny nose”
· Symptom analysis/HPI: Patient has been with those symptoms
for a week, the runny nose and eye itchy are the same but the
sore throat got worse lately, the discharge is clear. There is
tenderness around the nose. The Symptoms improve drinking
water and some drops throat lozenges. Denies fever, no nasal
blockage, no chills.
Review of Systems (ROS)
· General: Fatigued, Generalized Weakness.
· HEENT: Runny nose, eyes itchy, sore throat, difficult
swallowing, blurred vision when reading, no double vision.,
denies block nose and no bleeding.
· Neck: Denies neck pain, able to rotate his neck laterally and in
and upward position
· Lungs: No cough, shortness of breath, PND, or orthopnea
· Cardiovascular: No pressure, squeezing, tightness, heaviness
or aching about the chest, neck, axilla or epigastrium
· Breast: Denies any pain or lumps
· GI: Denies Abdominal Pain
· Female genital: Denies dysuria, frequency and urgency when
urinating
· GU: Denies dysuria, no frequency and urgency when urinating
· Neuro: No burning or tingling, sensation present in all
quadrants
· Musculoskeletal: No joint pain no restriction motions.
· Activity & Exercise: no habits of exercise.
· Psychosocial: anxious about the disease.
· Derm: denies any rash, bums or recent lesions.
· Sleep/Rest: more than 6 hours a day but with difficult to
breath.
Objective Data/Physical Exam
· BP 141/82 TPR 99.1 HT 170 cm WT.

3. BMI 30.1 O2: 99%
· General: Well-groomed, appropriate posture and gait, normal
affect, obesity
· HEENT: Tenderness frontal and right maxillary sinus, Weber
and Rinne test intact, cranial nerves intact, no hearing loss,
vision left eye 20/20 right eye 20/40. whitish discharge noted
from the nose. Edema and erythema of nasal mucosa, uvula and
Tonsils, redness noted. Halitosis presents.
· Neck: thyroid gland intact no nodules no lymphadenopathy
noted
· Pulmonary: lungs clear to auscultation, no adventitious sound
throughout the lungs
· Cardiovascular: no abnormal heart sounds normal physiologic
S1/S2 present, normal PMI
· Breast: no bumps or lesions
· Abdomen: no abdominal distention, no pain on percussion or
palpation, active bowel sounds any signs of liver or spleen
enlargement
· Rectal: Refuse assessment
· Male genital: Denies discharge, dysuria, pyuria, pain that
radiates to the groin
· Neuro: Cranial nerves intact, no cerebellar dysfunctions, alert
x4
· Derm: Acanthosis nigrins around the neck, papules,
comedones on the face
· Psych: anxious about disease process
ASSESSMENT
Main Diagnosis:
· Allergic Rhinitis
Differential diagnosis:
· Infectious Rhinitis
· Rhinitis Medicamentosa
· Influenza
· Seasonal allergic.
· Asthma

4. PLAN:
Labs and Diagnostic Test to be ordered:
· CBC with Differential (pending results)
· Rapid Strep Test done in office (positive in office)
· Influenza Swab (negative in office)
· Covid -19 Swab (pending results)
Education
· Avoid exposure to known allergens
· Frequent hand washing
· Monitoring signs of complication such as fever, change of
discharge color, change of senses of smell and taste, nose
bleeding.
· Take medications as prescribed.
Non-Pharmacologic treatment:
· Drink plenty of Fluids
Pharmacological treatment:
· Loratadine 10 mg po daily
· Saline nasal drop qid
· Ibuprofen 600mg qid PRN for pain
Follow-ups/Referrals
· Follow up in 2 week. Office
· will call you when lab work is available.
· No referrals needed at this time.
References
Barbara Bates a Guide to Physical Examination
Buttaro, T. et al. (2017). Primary care: a collaborative practice.
St. Louis, MO: Elsevier.
Gupta, N., Singh, R., & Saxena, R. K. (2019).
Porter, R. S. (2018). The Merck manual: of diagnosis and
therapy. Rahway: Merck Sharp & Dohme Corp. 246 (2080-2080)
Webmd.com

5. Dyspareunia.
Student: (19-SM0627)
Miami Regional University.
Day of encounter: 10/06/2020
Preceptor name:
Clinical Site: G & G Medical Center
Instructor:
SOAP Note # 5 Dyspareunia
10
Demographic Information
Encounter Date: 10/06/2020 Patient initials: D.G
Age: 45 y/o Race: Hispanic Gender: Female
Insurance: Ambetter Information Source: PatientSUBJECTIVE
Chief complaint: "I feel pain during intercourse"

6. History of present illness (HPI): Patient 45 years old Hispanic
female, came to the clinic and complains intense pelvic pain
during intercourse. Patient is crying during interview and she
said that is not the first time that this occurs. She has had the
same problem since then, she has been without a partner for a
year, now she has a new partner four months ago and she is very
sad because she is afraid of losing him. Patient denies vaginal
discharge, bleeding, burning when urinating or fever. Menarche
was at the age of 10 and was sexually active since the age of 18
yrs.
Allergies: Iodine.
Medication History: No medication Family History
Mother Alive 66 y/o /Hypothyroidism
Father Alive: 70 y/o/Positive Hx: HTN 1 Brother Alive 47 HTN
Son Alive 20 y/o Healthy
Negative Hx for Cancer, Dead for CV event, Genetical disease
Patient History
Past medical History (PMH): Negative for Chronic Disease
Genetical History: Negative Infection History: Negative
Menstrual History:
Age of menarche: 12 years
LMP: 09/14/2020
Menses Monthly: Yes
Frequency: 7-9 Days Q/ 28 days
Menarche: 11 y/o
On Contraception Tx: No
Current method of contraception being used: Condom but
expresses some discomfort with the mentioned method.

7. Hormone replacement Therapy: none
Menopause: N/A
Fertility: No difficulty conceiving.
Sexual history: Denies history of sexual dysfunction but around
10 years ago felt the same situation.
Obstetric History
Total Preg.
Full Term
Premature
Ab Induced
Ab Espontan
Ectopic
Multiple
Living
3
1
0
1
1
0
0
1
Date: 08/09/2000
GA week 40.1
Weigh 7.1
Sex Male
Deliver Vaginal
Complic No

8. Hospitalization: No previous hospitalization.
History of mental illness/personality disorders: None.
Physical trauma/falls: No reported during the last twelve
months.
Surgeries: Denies past surgical procedures. No previous
gynecologic surgeries.
Exposure: Patient is living in an apartment and does not
complaint of any financial difficulties, she is working like a
cashier with sedentary life. No knows HIV exposure during the
last year. No blood transfusions or other blood components or
tissues have been received. No identified environmental
exposure to asbestos, radiations, or any other chemical
substances. No exposure to the sunlight during the regular daily
activities.
Immunizations: Vaccines updated (Flu Vaccine: 12/15/2019).
Exercise: Usually no practices exercise.
Diet: Patient does not follow a specific diet. The diet is rather
rich in carbohydrate, vegetables, and proteins.
Social History: Patient is well socially integrated, non-smoker,
does not consume alcohol frequently. Consume coffee at least
three times a day. Denies using illegal drugs. She is working in
a Shop (cashier). Lives with her parents and her son 20 y/o. She
describes her home dynamic, functional and happy.
Educational level: High school completed.
Sexual Behavior: Patient is heterosexual and has not a stable
sex partner at the present.
Last annual physical exam: 11/21/2019
Screening:

9. Pap smear: 12/15/2019: Negative HIV /STD Test:
12/15/2019Negative
Monthly Breast Self-examination: Yes Mammogram:
12/23/2019 Normal
Bone density: N/A
Colon cancer Screening: N/A Skin cancer Screening:
12/15/2019
REVIEW OF SYSTEMS:
Systemic: No fever reported. Denies fatigue or weight loss.
HEENT. Head: No history of trauma, no complaining of
headache. No sinus pain or any other facial pain is stated.
Neck: Denies pain or stiffness. No swollen glands in the neck.
Eyes: Denies blurring vision, double vision, redness, or eye
discharge. Oto-laryngeal: Denies change in hearing, ringing in
ears, pain, or discharges from external auditory canal. Denies
watery nose discharge, congestion, or nasal bleeding. Denies
bleeding gums. No hoarseness.
Cardiovascular: Denies chest pain, palpitation, or edema on the
lower extremities. No varicosities or history of DVT.
Respiratory: Denies shortness of breath, cough, or wheeze. No
complaints of chest congestion.
Gastrointestinal: Denied appetite problems. No dysphagia.
Denies heartburn or bleeding. No complaints of flatulence.
Denies nausea or vomiting. Denies hematochezia. No diarrhea
or constipation. Last bowel movement: 10/06/2020.
Genitourinary: Denies changes in urinary habits, normal urinary
frequency, denies urgency, nocturia or hematuria. Denies
history of kidney stones, flank pain, cloudy urine, or bad smell.
Gynecological: the menstrual period normal, with moderate
flow every month. No accompanying symptoms, painful on the
lower abdomen the two first days as usual relieve with
application of warm compresses and Tylenol. Denies vaginal
discharge. Complains intense pelvic pain during intercourse
with deeper entry.

10. Breast: No mass noted, no fulness sensation, pain or discharge
reported. No prior history of breast biopsy, lesions, pain, or
discharge.
Endocrine: Denies hot or cold intolerance, polyuria, or
polyphagia. Denies thyroid problems. Hematologic: Denies
anemia, bruising, adenomegaly, unusual bleeding, petechiae,
left upper quadrant or bone pain.
Musculoskeletal: No history of falls reported, denies weakness,
muscular pain, swollen or any other inflammatory symptoms in
the joints. Denies joint pain, limited ROM, difficulty walking or
trouble reaching above head.
Neurological: Denies loss of memory, seizures, seizures or
fainting lightheadedness, facial pain, gait imbalance or changes
in LOC. Denies tremors, muscle weakness, numbness, tingling
or sleeping disturbances.
Psychological: Patient states no changes in mood, denies
anxiety, depression, or insomnia. Denies low self-esteem,
feeling sad, social isolation or attention deficit, no change in
thought patterns. Enjoyment of activities is sometime
interrupted during the pain.
Integumentary: Denies pruritus, bruises, or rash. No new nevus.
Denies history of contusions, lacerations, burns or history of
skin cancer.
OBJECTIVE:
Physical Exam
Vitals Signs: Temp (Axillary): 96.7 0F. BP-sitting L: 120/75
mmHg (BP cuff size: Regular). Pulse Rate-Sitting: 78 bpm.
(regular rhythm). RR: 18 per min. Height 5”4”, Weight: 141 lbs.
BMI: 24.2Kg/m2 (normal). Oxygen Saturation: 98 %. Pain
Scale/Rate: 3/10.
General appearance: Patient in not apparent acute distress,

11. speaks fluent, coherent, alert and oriented x3. Well hydrated,
well nourished.
Head: Normocephalic, symmetric head, no signs of trauma.
Normal sinuses, maxillary and frontal to palpation.
Neck: No visible mass. No lymphadenopathy noted. Thyroid in
the middle, no palpable. No palpable masses or tenderness,
trachea is midline. No JVD.
Eyes: No strabismus observed during exploration, normal
extraocular muscles function, no discharge from the eyes, sclera
is white, conjunctiva pink. PERRLA.
Ears: Normal tragus and external canal. Meatus are normal. No
swollen or reddened. Bilateral tympanic membranes were intact
and pearly gray with light reflex. No erythematous, scarred or
hemorrhage. No pus or serous exudate. No hearing loss on
bilateral whisper test.
Nose: No external deformities of the nose. Nasal mucosa moist
and pink with clear drainage, septum midline. Nasal turbinate
no erythematous, no swollen. No sinus tenderness.
Oral Cavity: Oral mucosa moist and pink. No lesions suggestive
of malignancy or infections. Normal gums and palate, no
bleeding or hypertrophy. Good hygiene, no caries or abscess
detectable to single inspection, normal dentition.
Pharynx: Moist and pink, no presence of plaques or exudate.
Absence of tonsils. No petechias, no strawberry tongue. Normal
pharynx and uvula to inspection, gag reflex presents and
unaltered.
Lymph Nodes: No adenomegaly detected along the ganglion’s
chains.
Chest: Symmetric chest wall, follow up the breading movement.
Lungs: Respirations are regular, equal, and unlabored with
symmetrical chest expansion. No cyanosis or nasal flaring
observed. Normal breath sounds to palpation, unremarkable
percussion. Lung sounds clear to all lung fields. No wheezing,

12. stridor, crackles, or rhonchi noted.
Cardiovascular: Normal chest wall, absence of orthopnea,
collateral circulation or edema on lower extremities, no
clubbing or cyanosis observed. No pericardial friction rub
heard. Regular rate and rhythm, heart sounds of S1 and S2, no
bruits, murmurs found to auscultation, no extra heart sounds,
PMI at 5th intercostal space, midclavicular line. No pericardial
friction rub heard. No gallops, murmurs, or opening snaps.
Carotid, apical, radial femoral and pedal pulses present and
strong, capillary refill 2 seconds.
Abdomen: Inspection: Symmetric, is watched flat,
nondistended, no visible masses, few vertical striaes present.
Auscultation: Bowel sound active in all 4 quadrants. No bruits.
Palpation: soft, no pain when palpating, no involuntary
guarding or rebound tenderness observed, no signs of peritoneal
irritation, no palpable masses. No hepatomegaly or
splenomegaly. Percussion: Normal.
Genitourinary: Bimanual palpation does not reveal signs of
enlarged kidneys. Costovertebral angles do not reveal
tenderness. No palpable or percussed bladder.
Gynecological: Patient positioned lying supine on the office
examination table with the knees flexed, and with the feet in
supporting stirrups.
Inspection: Normal general appearance of the external genitalia,
adequate hair
distribution. Scar of a previous medio-lateral right episiotomy.
No presence of caruncle and other findings to inspect the
urethra, erythematous and mild swelling to labia majora and
vaginal introit. No vesicular lesions observed at this moment.
No perineal lesions. Vagina: Atrophic labia with decrease
rugae, pale pink, Small amount of thin, clear non-odorous
discharge noted. No evidence of prolapse.
Palpation: Mild discomfort with exam, painful. Mild vaginal
tenderness. Free of masses to bilateral adnexal area. No ovary

13. enlargement. No palpable Bartholin’s gland.
Speculum exam for Vagina and cervix.: Painful introduction to
vaginal canal. Vaginal walls free of masses, no bleeding.Cervix:
pink, non-friable without lesion or mass. No discharge
appearing from cervical oz.
Bimanual exam: Unremarkable vagina, cervix, uterus, and
adnexal exam. No signs of pregnancy.
Pregnancy test done, negative result.
Breast: Inspection: Bilaterally symmetrical breast, no changes
in color, no irregularity observed. No Ulceration of the skin or
area of thickening noted. No observable convex skin
changes. No evidences of retraction phenomena.
Palpation: Right/Left breast, no palpable mass on any of the
four quadrants. No enlargement of axillary or supraclavicular
nodes are palpated
Endocrine: She had no goiter, no ophthalmopathy, no
hyperhidrosis, no tremor.
Hematologic: No adenomegaly found. No spleen/liver palpable.
Musculoskeletal: Normal gait. No muscular atrophies observed,
no evident deformities, no stiffness observed, range of motion
within normal limited, normal joints. Fingers, feet, and toes are
normal. Spine without deformity.
Neurologic: AAOx3. Keeps adequate communication ability, no
concentration or attention deficit noted during the exploration.
Normal gait and balance observed. Sensation intact. Normal
motor activity. Deep tendon reflexes symmetrical and equal
bilaterally. Normal function of all cranial nerves (from I to
XII). Bilateral UE/LE strength 5/5.
Psychiatric: Patient is euthymic, with normal level of mood,
language, and communication. The affect was normal just sad

14. because of the current situation.
Integumentary: No observable diaphoresis. No discoloration
presents, absence of cyanosis in skin, lips, no suspicious nevi,
good turgor on examination. Hair: Normal distribution
according to the gender and age. No hair loss in the lower
extremities was observed.
Nails: Pink with normal appearance, absence of cyanosis in
nails. No clubbing of the fingers. No lesions.
ASSESSMENT:
Dyspareunia (ICD-10 N94.10). Patient’s symptoms are
consisting with a diagnosis with recurrent genital pain
associated with sexual activity. Dyspareunia is painful sexual
intercourse due to medical or psychological causes. It can affect
a small portion of the vulva or vagina or be felt all over the
surface. (Al-Abbadey, Liossi, Curran, Schoth, Graham, 2016).
Dyspareunia is not exclusively due to lack of lubrication or
vaginismus and is associated with distress or interpersonal
difficulty. May be the result of organic, emotional, or
psychogenic causes. It could be primary in these cases present
throughout one’s sexual history with potential relationship
between primary dyspareunia and vaginismus, low libido, and
arousal disorders. Secondary arising from some specific event
or condition (e.g., menopause, drug) More than 50% of all
sexually active women will report dyspareunia at some time.
(Domino, F., 2020).
Superficial dyspareunia: pain at, or near, the introitus or vaginal
barrel associated with penetration.
Deep dyspareunia: pain after penetration located at the cervix or
lower abdominal area. (Merck Manual)
Differential diagnosis
1. Pelvic Inflammatory Disease (ICD 10 N73.9). Pelvic
inflammatory disease is a term for infection of the female

15. reproductive organs such as ovaries, fallopian tubes, uterus,
cervix, or vagina, characterized by abdominal pain, dysuria and
dyspareunia. Most common causes are STD’s (gonorrhea and
Chlamydia), foreign device such as IUD and abortion. The
patient in this case complained of dyspareunia intense pelvic
pain during intercourse but denies vaginal yellowish discharge
or dysuria which leads us to a diagnosis of PID. (Al-Abbadey,
Liossi, Curran, Schoth, Graham, 2016).
2. Acute cystitis (ICD 10 N30.01). Is the infection of the
bladder, or of the urethra and sign and symptoms include
bacteriuria, frequency, urgency, suprapubic pain and or
hematuria. It is defines as an invasion of microorganism to the
bladder. Women tend to get infections more often than men
because their urethra is shorter and closer to the anus. This
patient denies symptoms like dysuria, frequency, urgency or
hematuria, her complaint is pain during sexual relation. (Al -
Abbadey, Liossi, Curran, Schoth, Graham, 2016).
3. Vaginal irritation (ICD-10 N98.8). Due to pain during
intercourse and not complaint vulvar irritation by the patient
ruled out due to the absence of etiology in this case.
PLAN:
Diagnostic tests ordered to support the diagnosis:
Lab test:
· Complete blood count (CBC) with differential to search for
evidence of infection
· Erythrocyte sedimentation rate (ESR)
· Urinalysis (UA)
· Abdominal ultrasonography
· Smear, Wet mount examination for infectious agents.
· Pap smear (Cytopathology cervical/vaginal)

16. Pharmacological treatment:
The goal of pharmacotherapy is to treat sexual pain:
· Ibuprofen 800 mg 1-tab P.O TID as needed for pain.
Non-pharmacologic treatment:
· Avoid chemical irritants such as douches and deodorant
tampons.
· Avoid stress
· Healthy food (High in fiber)
· Exercises
· Sitz baths may relieve the pain.
· Perineal massage.
Patient education:
Educate the patient and the parent regarding the nature of
problem, reassure both that there are solutions to the problem.
Emotions are deeply intertwined with sexual activity, so they
might play a role in sexual pain. Emotional factors include:
Psychological issues. Anxiety, depression, concerns about your
sexual abuse, fear of intimacy or relationship problems can
contribute to a low level of arousal and a resulting discomfort
or pain. Stress is other problems that provoke that situation.
This can contribute to pain during intercourse. It can be
difficult to tell whether emotional factors are associated with
dyspareunia. Initial pain can lead to fear of recurring pain,
making it difficult to relax, which can lead to more pain.
Delay sexual relation until symptoms clear or resolves.
Balance diet and avoid constipation, practice exercises
regularly.
Follow-up/Referrals:

17. Follow-up: Next office visit will be in 1 week for re-evaluation
and lab report.
Referrals: Referral mental health/counseling.References
Domino, F. J., Barry, K., Baldor, R. A., & Golding, J.
(2020). 5-Minute clinical consult 2021. Lippincott Williams &
Wilkins. 306-307.
The Merck manual of diagnosis and therapy. (2011). Merck.
Al-Abbadey, M. Liossi, C. Curran, N. Schoth, D.E. Graham,
C.A. (2016). Treatment of Female Sexual Pain Disorders: A
Systematic Review. J Sex Marital Ther. 42 (2):99-142.